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SURGICAL 


EMERGENCIES 


12  LECTURES 


DELIVERED    AT   THE    UNIVERSITY   OF    LEIPSIC 


BY 

DR.    L.  VON    LESSER 

Privat  Docent  of  Surgery 


TRANSLATED  AND  REVISED 

BY 

FREDERICK  A.  LYONS,  A.M.,  M.D. 

Surgeon   to   Bellevue   Hospital   Out  Patient  Department,    Fellow   of  the 
American  and  New  York  Academies  of  Medicine,  Etc. 


NEW  YORK 
BERMINGHAM     &     CO. 

18S3 


Copyright,  18%, 

by 

BERMINGHAM   &   CO. 


u  sr(o 


CONTENTS. 


LECTURE   I. 

PAGE 

Reasons  for-a  special  treatise  on  the  subject. — Considerations  for  the 
division  of  the  methods  of  aid  in  emergencies. — The  assistance  to 
be  rendered  either  to  a  single  individual  or  to  a  number. — Acci- 
dents to  numbers  both  in  times  of  war  and  peace 9 

LECTURE   II. 

Loss  of  vital  elements. — Losses  of  blood. — On  the  amount  of  blood 
present  in  the  organism  and  on  the  vascular  extent. — Experi- 
mental increase  of  the  amount  of  blood. — On  the  parts  where  the 
infused  blood  collects. — The  extensiveness  of  the  capacity  of  the 
vascular  system. — The  bleeding  to  death  of  plethoric  persons. — 
On  the  destiny  of  the  infused  blood. — On  cases  of  bleeding  to 
death. — The  course  of  the  blood-pressure  curves  in  those  cases. 
— Slow  and  quick  bleeding  to  death. — Qualitative  changes  of 
blood-mixture  in  phlebotomy 13 

LECTURES   III.  AND   IV. 

Haemostasis. — Blood-saving. — Hsemostasis,  especially  of  blood  from 
injured  arteries. — Progress  of  occurrences  during  the  healing  of 
arterial  wounds. — Proliferation  of  the  vascular  walls  and  thrombus 
organization. — Bruises,  cuts  and  punctures  of  arteries. — Foreign 
bodies  grazing  the  arterial  tube. — Catgut  as  material  for  ligatures, 
and  its  action  within  the  different  tissues. — Thread-ligature  in 
(aseptic)  wounds. — Instruments  for  vascular  ligatures. — Ligature 
of  artery  stumps  and  in  the  continuity  of  the  vessels. — Substitutes 
for  thread-ligature. — Haemostasis  at  certain  parts  of  the  body. — 
Places  for  the  compression  of  arterial  trunks 22 

LECTURE  V. 

Haemorrhages  from  veins. — Their  frequency,  cause,  and  occur- 
rence.— Phlebitis. — Periphlebitis. — Phleboplastic  haemorrhages  of 
Stromeyer. —  Spontaneous  haemostasis. — Vein-ligature.  —  Substi- 
tutes for  vein-ligature. — Tamponing  in  sequestral  cavities,  in 
haemorrhages  from  the  rectum,  the  vagina,  the  uterus. — Treatment 
of  haemorrhages  from  the  nose. — Bellocq's  tube. — Bandage-wrap- 
ping.— Capillary    haemorrhages. — Search    for    bleeding    point. — 


11  CONTENTS. 

Tamponing  with  bandage*  wrapping. — Styptic  tampons. — Heat  and 
cold. — Hot  douches  as  safe  haemostatic  means. — Glow-heat. — 
Cautery  iron. — Galvano-cauterizer. — Paquelin. — Chemical  haemos- 
tatic means , 41 

LECTURE  VI. 

Bleeding. — Its  value  as  a  haemostatic  remedy. — Other  indications 
formerly  and  at  present. — Places  for  phlebotomy. — Phlebotomy. 
— Topography  of  the  elbow. — Technique  of  phlebotomy. — Phle- 
botomic  aneurisms.— Phlebotomy  on  the  foot  and  the  neck. — Arte- 
riotomy  and  its  present  indications. — Capillary  bleeding:  Its  real 
value. — Scarification. — Cupping. — Leeches. 

Transfusion.— Historic  periods. — Defibrinated  and  "intact"  blood. 
— Different  methods  of  transfusion. — Actions  of  the  blood-discs, 
of  the  serum  and  the  gaseous  contents  in  the  blood  of  different 
species  of  animals. — Significance  of  fibrin-ferment. — Central  arte- 
rial blood  infusion. — Venous  transfusion.  Ingress  of  air  into 
veins. — Result  of  experiments. — Blood-injection  under  the  skin 
and  into  the  abdominal  cavity. — Technique  of  transfusion. — Symp- 
toms in  transfusions. — Present  indications. — Territories  of  anae- 
mia.— Auto-transfusion 50 

LECTURE  VII. 

Impediments  to  the  supply  of  air. — Sudden  stoppage  thereof  in 
strangulation. — Foreign  bodies  in  the  trachea  and  oesophagus. — 
Perilaryngeal  swelling  of  the  tissues. — CEdema  glottidis,  struma. 
— Kropftod. — Gradual  narrowing  of  the  trachea  lumen. —  Croup 
and  diphtheria. — Paralysis  of  the  vocal  cords. — Tracheotomy,  pre- 
paratory to  other  operations. — Dilatation  of  tracheal  strictures. — 
Induction  of  artificial  respiration  in  chloroform  poisoning,  opium 
poisoning,  tetanus. — Modus  operandi. — Rapid  and  slow  suffoca- 
tion, their  causes  and  symptoms. — Dangers  of  suffocation  in  tun- 
nels and  mines;  to  divers,  aeronauts  on  high  elevations;  working 
in  compressed  air  (caissons  in  bridge-building). — Narcosis  in  com- 
pressed air  according  to  Paul  Bert. — Mechanism  of  artificial 
respiration. — Opening  the  cervical  bronchus. — Pharyngotomy. — 
Thyrotomy. — Thyrocricoid  laryngotomy. — Cricotomy  or  crico- 
tracheotomy. — Supraglandular  and  infra-glandular  tracheotomy. 
— Procedures  in  tracheotomies.— Bose's  rectangular  dissection  of 
the  trachea. — Insertion  of  the  tube.— Removal  of  croup  mem- 
branes and  foreign  bodies. — Sucking  out  fluids  not  to  be  done  in 
diphtheria. — Dimensions  of  tubes,  and  their  modes  of  fastening. 
— Dressing  of  the  wound  in  tracheotomy. — Painting  it  with  an 
eight-per-cent  solution  of  chloride  of  zinc. — Inhalation  through 
the  wound  of  tracheotomy. — Removal  of  the  tube. — Impediments 
to  respiration  after  the  tracheotomy. — Granuloma. — Strictures. — 
Posture  of  the  patient  in  tracheotomy. — Instruments  and  para- 
phernalia for  tracheotomy . . . 73 

LECTURE  VIII. 

Impeded  passage  of  alimentary  substances  through  the  intestinal 
canal. — Impediments  in  the  pharynx  and  cesophagus:  Topo- 


CONTENTS.  ill 

graphy  of  the  latter. — The  most  narrow  points  in  the  oesophagus, 
as  seats  of  foreign  bodies,  tumors  and  strictures. — Removal  of 
foreign  bodies  from  the  faucial,  cervical,  and  thoracic  parts  of  the 
oesophagus. — Instruments. — CEsophagotomy. — Indications,  mode 
of  procedure,  after-treatment  of  the  wound. — Tumors  of  the  oesoph- 
agus.— Strictures,  their  etiology  and  treatment. — Catheterizing 
the  (esophagus.  Girard's  method. — Impediments  in  the 
small  and  large  intestines. — Hernias:  Reducible,  adherent, 
strangulated. — Hernial  orifice,  contents,  sack,  neck;  cysts  of  the 
sack. — Irreducibility,  its  etiology;  adhesions,  faecal  invagination. 
— Strangulation. — Acute  and  sub-acute  strangulation. — Apparent 
strangulation  and  its  treatment. — Site  of  strangulation. — Treat- 
ment of  hernia. — Taxis:  Mechanisms  of  Roser,  Busch,  Lossen. — 
Supporting  postures  in  taxis. — False  reduction. — Herniotomy: 
No  special  instruments  required. — Modus  operandi. — Incisions. — 
External  and  internal  hernial  incision. — Herniotomy. — Debride- 
ment multiple. — Reposition  of  hernial  contents. — Condition  of  the 
loop  of  intestine. — Suture  of  intestine  in  various  forms  of  gangrene. 
— Enteroraphy:  Treatment  of  artificial  anus. — Treatment  of  pro- 
lapsed peritoneum. — After-treatment  of  herniotomy. — Radical 
operation  for  hernia 97 

LECTURE  IX. 

Gastrotomy. — Indications. — History. — Spontaneous  gastric  fistulae. 
— Sites  for  opening  the  stomach. — Fixation  into  the  abdominal 
wall. — Attaching  the  abdominal  wound  with  the  gastric  mucous 
membrane. — Drainage-tube. — Obturators. — Condition  of  the  pa- 
tient in  gastric  fistula. — Artificial  (external)  oesophagus. — Opening 
the  duodenum. — Closing  gastric  fistulse. — Anomalous  anus. — 
Atresia  ani. — Degrees  of  defectus  ani  et  recti.— Opening 
atresic  anus. —  Lumbocolotomy.  —  Laparocolotomy.  —  Fistula  of 
small  intestines. — Artificial  anus. — Foreign  bodies  in  the 
rectum  and  in  the  vagina 119 

LECTURE  X. 

Dangerous  impediments  to  respiration  and  circulation  resultant 
upon  accumulation  or  retention  of  fluids  within  the  cavities  of  the 
body,  within  certain  hollow  organs  and  within  pathological  cystic 
spaces. 

Accumulations  of  fluids  within  the  thorax. — Historical  con- 
siderations.— Indications  for  the  evacuation  of  pleuritic  exudations 
in  general. — Re-absorption  by  the  pleura. — Pneumothorax,  chly- 
lothorax,  haematothorax. — Treatment  of  punctures  into  the  pleura. 
— Opening  of  the  thorax  and  special  indications  therefor. — 
Punctio  thoracis:  Thoracotomy. — Sites  for  opening  the  thorax. 
— Puncture  of  the  thorax. — Haemorrhage  from  the  intercostal 
vessels. — Trocars. — Apparatus  for  puncture  with  exclusion  of  air. 
— After-treatment  of  puncture. — Opening  the  plura  by  incision. 
— Partial  sub-periosteal  excision  of  ribs. — After  treatment  sub- 
sequent to  the  production  of  thoracic  fistula. — Accumulations  of 
fluids  and  air  in  the  pericardium  and  their  treatment. — Wounds  in 
the  heart. — Electropuncture  and  acupuncture  of  the  heart 130 


IV  CONTENTS. 

LECTURE   XI. 

II.  Free  and  cystic  accumulations  of  fluids  and  swellings 
from  retentions  in  the  abdominal  cavity. — Indications  for 
puncture  in  ascites. — Sites  of  puncture. — Operative  procedures. 
— Differential  diagnosis  from  ovarian  tumors. — Accumulations  of 
air  in  the  abdominal  cavity  and  intestines. — Echinococcus  cysts. 
— In  the  liver. — Modes  of  treatment. — Hydronephrosis. — Etiology 
and  treatment. — Cysts  of  the  ovaries. — Punctures  and  their 
consequences. — Solid  abdominal  tumors. 

Cystotomy. —  Indications.  —  Posterior  catheterism.  —  Foreign 
bodies  in  the  urethra. — Their  extraction. — Procedures  in  cystotomy. 
— Injuries  to  the  bladder. 

H^ematometra. — Hydrometra. 

III.  Perilous  contraction  of  the  cranial  space  (see  below)..  146 

LECTURE   XL— Continued. 

III.  Contractions  of  the  intracranial  space  perilous  to  life. 
— Normal  pressure  within  the  cranial  cavity. — Increase  of  intra- 
cranial pressure  and  transferability  of  the  cerebrospinal  liquor. — 
Its  relations  to  the  lymphatic  circulation. — Cerebral  hyperaemia 
and  its  consequences. 

Cerebral  compression:  Its  causes. — Intracranial  Haemor- 
rhages.— Injuries  to  the  venous  sinuses  and  their  treatment. — 
Haemorrhages  from  the  middle  meningeal  artery. — Symptoms. — 
Ligation  of  the  middle  meningeal  artery. — Haemorrhages  from  the 
cerebral  division  of  the  carotid  artery. — Haemorrhages  between 
the  dura  mater  and  pia  mater. — Reduction  of  space  by  fractures 
of  the  skull  and  foreign  bodies. — Complicated  injuries  to 
the  skull,  prognosis,  results. — Symptoms  of  cerebral  contusion. — 
Antiseptics  in  injuries  to  the  head. — Attainable  results. — Treat- 
ment of  infected  injuries  to  the  skull. — Action  of  antiseptic  douche, 
ice,  venesection,  purgatives,  inunctions  of  ung.  ciner. — Operative 
interference  in  inflammatory  stage  of  wounds. — Cerebral  abscess. 
— Difficulties  of  diagnosing  locality. — Treatment  of  open  and 
covered  cerebral  abscesses. — Cerebral  motions. — Causes. — Absence 
of  cerebral  motions. — Treatment  of  prolapsus  cerebri. 

Concussion  of  the  brain,  commotio  cerebri. — Symptoms. 
—  Pure  and  complicated  descriptions. — Theories. —  Light  and 
severe  cases. — Course  and  termination. — Treatment  of  concussion 
of  the  brain  and  sequelae. 

Trepanning. — Indications. — Instruments. — Mode  of  procedure. 
— Processes  which  occur  in  wounds  from  trepanning 161 

LECTURE  XII. 

Aids  in  accidents  to  masses  of  men. — Surgical  aid  in  war. — 
General  considerations. — Objective  points  of  military  surgery. — 
Task  of  each  individual  surgeon. — Information  requisite. — Lead- 
ing principles  in  military  practice. — The  battle-field. — Division 
of  the  wounded  into  those  who  are  capable  and  those  who  are  in- 
capable of  marching. — Places  for  immediate  dressings. — 
Selection  of  place. — Refreshment  for  the  wounded. — Classification 


CONTENTS.  V 

of  injuries. — Provisional  arrest  oi  dangerous  haemorrhages. — 
How  should  the  primary  dressing  be  made  ? — Antiseptic  com- 
presses, bandages,  cloths,  slings. — Splints,  their  improvisation. — 
Stretchers. — Means  of  transport  from  the  battle-field. — Medical 
staff. — Carriers  of  the  wounded. — The  place  of  permanent  dress- 
ing.— Only  for  the  wounded  who  cannot  march. — The  medical  staff 
and  its  organization. — Organization  of  the  sanitary  detachment. — 
Consulting  surgeons. — Assortment  of  the  wounded. — Tickets. — 
The  diagnosis  cards  formerly  employed. — Dressings  for  those  to 
be  immediately  removed. — Injuries  belonging  to  this  class. — Form 
of  dressing. — Drainage. — Course  and  contents  of  the  canal  of  the 
shot-wound. — Splints,  ready-made  and  improvised. — Means  of 
transportation  from  the  dressing-station  to  the  field-hospital,  to 
the  depot,  and  to  the  sanitary  train. — Improvisation  of  these 
means  of  transportation. — Injuries  in  which  operative  interference  is 
requisite. — No  resections  to  be  performed  at  the  dressing  station. 
— Injuries  which  cannot  bear  transportation ;  189 


EDITOR'S   PREFACE. 


The  work  herewith  presented  to  the  English  speaking 
medical  public  occupies  a  unique  position,  and  therefore 
needs  no  apology.  It  treats  of  subjects  that  have  been 
left  untouched  by  the  few  short  and  imperfect  works  on 
surgical  emergencies  that  have  appeared,  and  which,  in 
general  treatises  on  the  surgical  art,  are  so  encumbered 
by  the  mass  of  other  matter  that  they  are  inaccessible. 
Not  a  small  portion  of  the  book  is  devoted  to  subjects 
which  can  scarcely  be  classed  as  surgical  emergencies,  but 
which  may  be  included  in  the  term  "  Life-saving  Opera- 
tions." These  matters  are  extremely  important  to  the 
practitioner  who  has  not  the  time  to  wade  through  ponder- 
ous tomes  and  innumerable  journals,  and  they  are  dealt 
with  in  a  precise,  sententious  and  masterly  manner.  Many 
of  them  are  so  recent  in  their  origin,  that  they  have  not  as 
yet  even  been  incorporated  in  the  text-books.  Thanks  are 
due  to  Dr.  Ferd.  C.  Valentine  of  this  city,  for  his  invalua- 
ble assistance  in  the  preparation  of  the  manuscript. 

FREDERICK  A.  LYONS. 

244  West  Forty-ninth  St.,  New  York. 


PREFACE. 


I  am  induced  to  publish  the  following  course  of  lectures 
by  the  great  interest  evinced  by  my  hearers  in  the  subject 
treated  of. 

I  am  perfectly  conscious  of  the  imperfections  of  this  little 
work.  Besides,  I  have  lacked  the  requisite  leisure  to  put  the 
finishing  touches  to  every  detail,  as  I  should  have  liked. 
But  who  has  succeeded,  in  this  busy  bustling  decade,  in 
writing  a  book  at  once  so  interesting  and  weighty  as 
Diefenbach's  "  Operative  Surgery,"  or  so  deeply  instructive 
as  Virchow's  "Cellular  Pathology,"  or  so  inspiring  as 
Billroth's  "General  Surgical  Pathology,"  appeared  to  us 
in  the  years  of  our  academic  life  ? 

Above  all  things,  I  have  striven  to  be  true:  not  to  say 
more  nor  less  than  was  necessary  to  the  elucidation  of  the 
subject. 

The  clinical  preceptor,  who  has  followed  without  pre- 
judice the  progress  of  surgical  science,  and  whose  ambi- 
tion is  not  to  be  satisfied  by  the  brilliant  success  of  his 
operations  alone,  will  find  but  little  that  is  new  in  this  book. 
On  the  other  hand,  I  hope  the  young  practitioner  will 
gladly  take  it  up  for  advice,  when  he  leaves  the  student's 
life  for  independent  activity  in  his  profession,  and  suddenly 
becomes  conscious  of  the  great  responsibility  which  he  has 
taken  upon  himself.  For  to  this  day,  as  formerly,  even  to 
the  most  industrious  of  young  physicians,  and  even  at  our 
best  universities,  that  practical  training  and  that  confi- 
dence are  lacking,  which  are  alone  obtainable  within  hospi- 
tals. Most  of  them  have  seen  much,  learned  much,  but 
experienced  little. 

But  even  the  physician,  who  has  had  the  privilege  of  en- 
larging his  knowledge  by  daily  hospital  practice,  may  be 


PREFACE. 

stimulated  by  the  present  volume  to  ponder  over  his  own  ob- 
servations. 

As  regards  citations,  only  those  works  have  been  noticed 
which  have  been  a  source  of  instruction  to  myself  or  which 
excel  by  their  impartial  presentation  of  the  literature  of  the 
subject.  I  therefore  hope  not  to  offend  any  one,  nor  call 
forth  touchy  questions  of  priority.  I  dedicate  this  small 
volume  to  Bernhard  von  Langenbeck  and  Carl  Ludwig,  to 
whom  I  am  indebted  for  the  best  I  have  learned.  To  them 
belongs  the  credit  for  all  that  is  good  and  useful  within 
these  pages. 

L.  VON  LESSER. 

Leipsic. 


SURGICAL  EMERGENCIES. 


LECTURE  I. 


Reasons  for  a  special  treatise  on  the  subject. — Considerations  for 
the  division  of  the  methods  of  aid  in  emergencies. —  The  assist- 
ance to  be  rendered  either  to  a  single  individual  or  to  a  number. — 
Accidents  to  numbers  both  in  times  of  war  and  peace. 

Gentlemen  :  The  separate  discussion  of  surgical  aid  in 
cases  of  pressing  danger  to  life  is  not  included  in  theore- 
tical lectures  on  Surgery.  Its  aim  is  a  direct  completion 
of  our  clinical  instruction. 

Conditions  which  are  directly  life-endangering  are  but 
seldom  seen  at  the  clinic;  for  it  would  depend  upon  chance 
that  such  cases  should  present  themselves  for  aid  just 
during  the  hours  of  instruction.  Should  this  even  be  the 
case,  the  symptoms  of  the  dangerous  condition  and  the 
means  of  assistance  appear  in  an  altogether  too  favorable 
light,  simply  because  at  the  clinic  the  most  favorable  cir- 
cumstances imaginable  obtain  as  to  the  place  of  operation, 
professional  experience,  and  intelligent  assistance. 

The  same  cases  will  appear  to  you  entirely  different  in 
your  own  practice.  You  will  often  be  called  upon  to  ex- 
ercise your  profession  when  life  is  in  peril,  within  narrow, 
badly  lighted  rooms,  surrounded  by  despairing  relatives, 
panic-stricken  friends,  and  distrustful  old  women, 

In  such  cases,  only  the  firmest  principles  and  technical 
surety  will  give  you  that  measure  of  self-confidence  which 
forthwith  commands  respect  from  both  the  patient  and 
those  surrounding  him,  but  which  also  preserves  from  in- 
excusable passivity  as  well  as  from  irresponsible  officious- 
ness    (delirium  operatorum).      Secondly,  surgical    aid    in 


IO  SURGICAL  EMERGENCIES. 

sudden  emergencies  needs  a  separate  discussion,  because 
the  course  of  instruction  differs  materially  from  that  in  a 
clinic.  In  the  latter  only  selected  cases  are  laid  before  the 
student.  Not  only  their  history,  but  also  the  special  indivi- 
duality of  the  patient  is  circumstantially  considered,  in  ad- 
dition to  an  exhaustive  investigation  of  the  disease. 

In  emergencies  where  the  patient's  life  is  in  imminent 
danger,  or  even  where  he  is  unconscious,  and  those  around 
him  are  unfit  for  thought  or  action,  unmanned  by  the  sud- 
denness of  the  misfortune,  then  it  falls  upon  you  to  re- 
cognize at  once  the  chief  symptom  and  to  take  promptly 
the  right  measures  to  combat  it.  Even  within  the  walls  of 
the  hospital  the  urgency  of  the  need  scarcely  permits  a 
more  minute  demonstration  of  the  separate  phases  of  the 
disease. 

It  is  exactly  for  this  reason  that  we  feel  justified  in  leaving 
for  the  present  the  sick-bed  for  the  experiment-table  at  the 
clinic,  for  the  study  of  life-endangering  conditions.  We 
certainly  concur  in  the  protest  against  simply  transferring 
the  results  of  experiments  upon  animals  to  phases  of  disease 
in  man;  we  would  specially  recall  to  you  the  results  of 
vaccine-tuberculosis  as  compared  with  the  progress  of 
human  phthisis.  For  conditions  dangerous  to  life,  however, 
experi?nents  upon  animals  serve  excellently  well,  as  prototypes  of 
disturbed  life  functions.  At  the  experiment-table  we  are  en- 
abled to  study  much  more  precisely  the  separate  phases  of 
a  disturbance  without  regard  to  the  subsequent  preserva- 
tion of  the  individual's  life.  It  is  in  my  opinion  exactly 
through  this  peculiarity  in  the  method  of  instruction  that 
surgical  aid  in  sudden  emergencies  possesses  an  advantage 
over  the  other  applications  of  surgery. 

But  you  will  not  only  meet  such  emergencies  rarely  in  the 
clinic,  and  not  only  does  the  course  of  instruction  appear 
different,  but  also  emergencies  occupy  a  distinct  technical 
position  among  surgical  operations.  As  remarked  above, 
the  latter  are  performed  at  the  clinic  in  a  specially  chosen 
operating-room,  amidst  the  best  possible  conditions  of  light, 
ventilation'  and  temperature.  Here  it  is  possible  to  get 
ready  all  necessary  instruments,  to  procure  new  ones,  or 
even  to  have  such  constructed  as  best  serve  the  special  case. 

But  when  we  meet  in  our  every-day  practice,  unexpect- 
edly and  unequipped,  conditions  endangering  life,  then  we 
are  often  called  upon  to  improvise  the  necessary  instru- 
ments, to  accomplish  much  with  imperfect  materials,  and  in 


SURGICAL  EMERGENCIES.  II 

spite  o  tne  scantiness  of  our  means  to  approach  as  near  as 
possible  the  strict  requirements  of  the  art  of  operating,  and 
particularly  that  of  dressing,  of  the  present  day. 

The  surgeon's  talent  for  improvising  will  be  particularly 
challenged  by  the  accidents  of  war.  It  is  true  this  talent  is 
a  natural  gift,  but  its  development  and  cultivation  must  not 
be  left  to  the  moment  of  necessity — it  must  be  schooled  and 
exercised  beforehand.  Modern  military  surgery  has  learned 
to  appreciate  sufficiently  the  importance  of  this  fact. 

The  surgeon's  aid  in  emergency  differs  according  to  its 
being  rendered  either  to  a  single  individual  or  to  a  greater 
number  of  people. 

Of  course  the  consideration  of  the  aid  to  be  rendered  to 
a  single  individual  will  form  the  basis  of  our  remarks  on 
its  application  to  a  number  of  people.  The  exact  apprecia- 
tion of  its  essential  principles  will  facilitate  the  establish- 
ment of  those  rules  which  are  to  guide  us  in  cases  of  acci- 
dents befalling  larger  numbers  of  people,  and  where  it  is  of 
chief  import  to  select  correctly  the  right  kind  of  aid  accor- 
ding to  its  urgency,  consequently  to  divide  labor  most  effect- 
ively and  where  the  surgeon's  activity  in  organizing  out- 
weighs for  the  moment  that  of  operating. 

Mortal  dangers  befalling  single  individuals  may  be  chiefly 
classified  as  follows; 

A.  Cases  of  loss  of  vital  elements  (blood). 

B.  Cases  of  obstruction  to  the  regular  reproduction  of  the 
same  (air,  nourishment). 

C.  Cases  in  which  the  accumulation  of  material  endan- 
gers either  mechanically,  or  chemically,  or  simultaneously 
in  both  ways  the  constituent  parts  of  individual  organs  or 
the  entire  organism  (ascites,  empyaema,  emphysema  diffu- 
sum,  urinary 'retention,  quickly  growing  tumors,  abscesses 
or  blood-infiltrations,  poisoning  by  gases,  such  as  carbonic 
oxide,  carbonic  acid,  hydrosulphurous  acid  and  chloroform, 
or  by  fluids,  such  as  opium,  morphine,  septic  substances,  etc.). 

The  above  classification  corresponds  also  to  the  contents 
of  the  main  chapters,  and  the  surgical  manipulations  to  be 
treated  of  therein,  viz.: 

I.  Haemostasis.  II.  Air-supply  in  cases  of  suffocation 
and  poisoning.  III.  Laryngotomy  and  gastrotomy,  treat- 
ment of  constriction  of  the  intestines,  atresia  ant  et  defectus 
aniy  and  the  formation  of  artificial  anus.  IV.  Treatment  of 
the  accumulation  of  fluids  in  the  pleura,  peritoneum,  blad- 
der, uterus,  etc.     V.  Treatment  of  quickly  growing  cystic 


12  SURGICAL  EMERGENCIES. 

and  solid  tumors  (oviarian  cysts,  echinococci,  struma,  solid 
abdominal  tumors). 

For  aid  in  emergencies,  in  accidents  to  numbers,  we  shall 
use  as  a  type,  the  aid  in  military  cases,  both  on  the  battle- 
field and  in  the  first  halting-places,  with  due  regard  to  the 
rules  of  dressing  for  transport,  and  for  means  of  transport 
to  the  rear. 

The  difference  of  accidents  in  factories,  mines,  buildings, 
water-works,  on  railroads,  etc.,  compared  with  casualties  of 
war,  consists  in  the  fact  that  in  the  latter  we  have  to  deal 
mainly  with  a  quite  particular  form  of  injury. 

In  contrast  with  gunshot  wounds  of  the  bones  and  of  the 
viscera,  as  they  almost  exclusively  characterize  modern  war- 
fare, the  calamities  of  peace  bring  before  us  in  various  num- 
bers injuries  by  explosion,  burns,  bruises  and  contusions. 

As  regards  the  technique  of  operations  I  shall  confine  my- 
self to  an  exact  presentation  only  of  the  most  useful  method 
and  to  the  enumeration  of  those  instruments  only  which  are 
absolutely  necessary  to  a  hasty  operation,  because,  as  I  em- 
phasized above,  we  must  learn  to  perform  our  task  with  the 
least  amount  of  extraneous  aid. 

You  will  see,  gentlemen,  that  the  territory  which  we  are 
jointly  to  traverse  is  very  extensive.  We  must  guard  against 
losing  sight  of  the  general  principles  in  the  examination  of 
the  details:  we  must  endeavor  to  bring  into  prominence  the 
essential  points  of  our  inquiry.  Thus  I  hope  you  will  be- 
come equipped  with  a  sufficient  amount  of  principles  to  be 
applied  in  cases  of  need,  in  which  you  will  have  the  difficult 
task  of  appearing  as  saviour.  The  words  of  Hamlet:  "'Tis 
all  in  being  ready,"  are  applicable  to  no  other  branch  of 
medical  activity  better  than  to  ours. 


SURGICAL  EMERGENCIES.  1 3 


LECTURE  II. 

Loss  of  vital  elements. — Losses  of  blood. — On  the  amount  of  blood 
present  in  the  organism  and  on  the  vascular  extent. — Experi- 
mental increase  of  the  amount  of  blood. — On  the  parts  where  the 
infused  blood  collects. —  The  extensiveness  of  the  capacity  of  the 
vascular  system. —  The  bleeding  to  death  of  plethoric  persons. 
— Oft  the  destiny  of  the  infused  blood. — On  cases  of  bleeding  to 
death. — The  course  of  the  blood-pressure  curves  in  those  cases. 
— Slow  and  quick  bleeding  to  death. — Qualitative  changes  of 
blood-mixture  in  phlebotomy. 

Gentlemen:  Hsemostasis  is  one  of  the  most  important 
chapters  of  surgery.  The  experience  of  the  operator  is  best 
evinced  by  his  certainty  on  this  subject.  The  great  num- 
ber of  methods  and  means  of  haemostasis,  which  already 
exist,  and  which  continually  increase,  are  the  best  proof  of 
the  difficulties  which  must  often  be  overcome. 

Before  entering  upon  the  theme  proper  it  is  our  duty  to 
form  an  exact  conception  of  the  vascular  system,  and  of  the 
distribution  of  blood  therein. 

You  see  here  two  dogs.  I  have  provided  the  carotid  of 
the  larger  and  the  jugular  vein  of  the  smaller  with  canulae. 
By  a  glass  tubing  I  unite  both  canulae,  and  after  expulsion 
of  the  contained  air,  I  cause — by  a  proceeding  to  be  explained 
in  Lecture  VI. — the  blood  of  the  carotid  of  the  larger 
animal  to  pass  over  into  the  jugular  vein  of  the  smaller  one. 
The  latter  remains  perfectly  quiet,  breathing  only  less 
often,  and  not  so  deeply.  After  a  short  time  the  larger 
animal,  losing  its  blood,  becomes  restless — its  restlessness 
increases,  and  at  last  it  falls  into  general  convulsions — it 
has  bled  to  faintness.  We  finish  our  transfusion  of  blood, 
and  leave  the  recipient  of  it  alone  for  the  present,  who,  be- 
ing freed,  runs  off  gaily,  and  at  the  most  is  troubled  for  a 
''short  time  after  the  operation  merely  by  tenesmus. 

But  in  the  animal  which  has  been  bled  to  exhaustion,  we 
see  that  the  blood  comes  but  drop  by  drop  from  the  pulse- 
less, almost  empty  carotid.  The  animal  moans,  breathes 
deep  and  heavy,  grows  gradually  weaker,  and  is  in  an  appar- 


14  SURGICAL   EMERGENCIES. 

ently  unconscious  state.  Now  we  place  the  feet  of  the  anim- 
al higher  than  its  head,  and  we  squeeze  out  its  extremities 
several  times  in  a  centripetal  direction,  and  bring  a  vigorous 
pressure  to  bear  upon  its  belly  and  thorax.  And  we  notice 
that  the  respiration  becomes  stronger,  likewise  the  pulse, 
and  the  blood  commences  to  flow  more  copiously  from  the 
canula  in  the  carotid,  so  that  we  might  yet  obtain  a  con- 
siderable amount  of  blood.  But  if  we  had  closed  the 
carotid  before,  the  animal  would  visibly  recover  and  could 
be  kept  alive  in  spite  of  the  great  loss  of  blood  and  its  life- 
endangering  symptoms. 

Let  us  now  return  to  the  recipient  of  the  blood.  He 
weighed  before  the  transfusion  4625  kilo,  after  the  trans- 
fusion 5050  kilo,  consequently  his  own  (hypothetical) 
amount  of  blood  of  32,375  grams  (7  per  cent  of  the  weight 
of  his  body,  was  increased  by  425  grams.  He  therefore 
possessed  after  the  transfusion  a  blood  amount  of  748.75 
grams,  or  14.8  per  cent  of  the  weight  of  his  body  in  blood. 

According  to  this  the  loser  of  the  blood  had  weighed  before 
the  transfusion  8.85  kilo.,  after  the  transfusion  8.37  kilo. 
He  had  therefore  suffered  a  loss  of  blood  of  480  grams  (Ex- 
periment of  Nov.  6,  1878).  In  another  experiment  (May  8, 
1878,)  the  recipient  of  the  blood  weighed  before  the  trans- 
fusion 3.75  kilo.,  after  the  transfusion  3.91  kilo.  The  in- 
crease of  blood  to  its  own  original  amount  of  262.5  (calcul- 
ated at  7  percent)  amounted  to  160  grams.  The  animal  con- 
sequently possessed  after  the  transfusion  422.5  grams,  or 
10.8  per  cent  of  the  weight  of  the  body  in  blood.  The  loser 
the  blood  weighed  4.43  kilograms  before  the  transfusion, 
4.21  kilo,  after  death,  by  the  squeezing  of  the  legs,  the  belly 
and  the  thorax,  50  grams  more  of  blood  could  be  obtained 
from  the  apparently  bloodless  animal.  Entire  loss  of  blood 
equals  220  grams  or  4.9  per  cent  of  the  weight  of  the  body  in 
blood. 

The  interesting  fact  that  the  entire  amount  of  blood  in- 
creases to  a  high  degree;  that  it  may  even  be  doubled  and 
trebled  without  endangering  the  vitality  of  the  organism, 
forces  the  question  upon  us,  in  what  parts  can  this  so  copiously 
infused  blood  find  room. 

At  first  we  might  imagine  that  the  vascular  system  has 
been  ruptured  somewhere,  and  that  the  superfluity  of  blood 
has  emptied  itself  as  such  into  the  tissues,  or  that  such  at 
least  has  been  the  case  with  the  watery  elements  of  the 
blood.     Here  the  results  of  dissection  of  animals  overfilled 


SURGICAL  EMERGENCIES.  1 5 

with  blood  are  of  importance.  They  show  that  in  the  re- 
gular course  of  transfusion  there  are  nowhere  any  blood  ex- 
travasations, nor  cedematous  places.  Nor  does  the  amount 
of  lymph,  which  during  the  transfusion  appears  in  an  in- 
creased quantity  from  the  opened  thoracic  duct  accord 
with  a  corresponding  proportional  decrease  of  blood-pres- 
sure. In  a  like  manner  we  notice,  by  a  comparison  of  the 
coloring  power  of  the  blood  before  and  after  the  transfusion, 
only  a  small  discharge  of  plasma. 

Worm-Muller  *  and  I  f  have  effectually  shown  that  the 
copiously  transfused  blood  remains  within  the  vascular 
system.  "And  this  result  is  obtained  from  a  comparison  of 
the  blood  pressure.  Thus,  Worm-Muller  was  enabled  to 
set  up  three  territories  for  the  capacity  of  the  vascular  system. 

In  the  first  territory  the  blood-pressure  rises  to  its  normal 
height,  when  an  anaemic  organism,  which  possesses  about 
1.5  to  2.5  percent  of  the  body-weight  less  blood  than  nor- 
mally, is  re-supplied  with  the  missing  fraction  of  its  normal 
blood  quantity.  In  the  second  territory  there  is  an  abnor- 
mal increase  of  blood  of  2.4  per  cent  of  the  body-weight. 
Here  the  blood-pressure  is  now  increased  beyond  the  usual 
limit,  now  it  sinks  below  it.  That  these  conditions  depend 
on  vaso-motor  influences,  is  proven  by  the  absence  of  these 
variations,  in  cases  where  the  transfusion  was  performed  in 
animals  with  a  severed  spinal  cord. 

The  third  territory  possesses  a  special  interest,  because 
in  spite  of  the  twofold  or  threefold  increase  of  the  quan- 
tity of  blood,  its  pressure  remains  invariably  at  the  nor- 
mal height,  and  can  in  no  manner  be  increased.  This 
proves  that  not  a  simple  adaptation  of  the  vascular  system 
but  a  continuous  enlargement  of  it  took  place.  A  com- 
parison of  the  blood-pressure  curves,  when  plethoric  animals 
are  bled  to  death,  furnishes  the  best  support  for  this. 

For  if  we  decrease  in  a  normal  individual  the  quantity  of 
blood  to  about  one  half,  the  pressure  will  fall  to  a  life-men- 
acing depth.  The  same  may  be  obtained  without  any  loss 
of  blood,  by  discontinuing  the  influence  of  the  vaso-motor 
centres  on  the  muscular  structure  of  the  vessels  by  means 


*  Worm-Miiller,  Die  Abhangigkeit  des  arteriellen  Druckes  von  der 
Blutmenge.  Berichte  der  konigl,  sachs.  Gessellschaft  der  Wissenschaf- 
ten.     Math-phys.  Classe.  Sitzung  vom  12  Dec,  1875. 

f  L.  v.  Lesser,  Ueber  die  Anpassungder  Gefassean  grosse  Blutmengen. 
Daselbst,  Sitzung  vom  8  August,  1874. 


l6  SURGICAL  EMERGENCIES. 

of  severing  the  spinal  cord.  By  doing  this  we  do  not  de- 
crease the  vascular  contents,  but  increase  the  vascular 
capacity. 

What,  then,  of  plethoric  individuals  ?  It  is  true,  in  bleed- 
ing to  death  they  yield  more  blood  than  normal  individuals. 

A  lively  dog,  2.39  kilo,  in  weight,  was  subjected  (Experi- 
ment Nov.  6,  1879,)  to  a  transfusion  of  blood  from  the  car- 
otid of  a  larger  animal.  He  thereupon  weighed  2.54  kilo., 
consequently  an  increase  in  blood  of  150  gr.  A  week  after- 
wards he  weighed  2.414  kilo.  At  being  bled  to  death  he 
yielded  184  gr.  of  blood,  while  in  proportion  to  his  ultimate 
body-weight  he  should  have  yielded  but  120.7  gr* 

On  the  other  hand,  in  smaller  losses  of  blood,  the  pressure 
falls  much  more  quickly  to  a  life-menacing  depth.  Indeed, 
this  may  occur  when  the  animals  possess  not  only  their 
original  amount  of  blood,  but  even  an  additional  part  of  in- 
fused blood.  They  are,  in  spite  if  it,  in  the  same  danger  as 
normal  individuals,  whose  blood  amount  may  have  been 
decreased  below  the  usual  quantity. 

Plethoric  individuals,  particularly  with  hyperemia,  are  conse- 
quently by  reason  of  the  enlargement  of  their  vascular  space  more 
susceptible  to  loss  of  blood  than  normal  organisms. 

But  the  other  question  arises,  whether  in  plethora  the  en- 
tire vascular  system  or  only  single  parts  of  it  are  subject  to 
enlargement. 

That  the  entire  accumulation  of  blood  does  not  take  place 
within  the  great  arterial  avenues  is  best  supported  by  the 
relative  immutability  of  the  blood-pressure.  Nor  does  the 
infused  blood  gather  within  the  large  veins.  This  we  see, 
in  the  first  instance,  by  dissection.  Nor  are  we  able  to  in- 
crease the  bloodpressure  or  the  phlebomtomic  quantity,  of 
animals,  bled  after  a  copious  infusion  of  blood,  by  squeezing 
out  of  the  veins.  To  no  greater  extent  is  the  blood-pressure 
influenced  by  division  of  the  vagus  nerve  as  the  number  of 
beats  of  the  heart  is  thereby  increased,  we  would  also  ex- 
pect that  a  greater  quantity  of  blood  would  be  forced  with- 
in the  same  unit  of  time  into  the  arterial  systen  if  much 
blood  had  accumulated  within  the  veins.  Moreover  the  di- 
rect measurement  of  the  tension  of  the  crural  veins  during 
hypersemia  shows  only  temporary,  not  permanent  increase. 
We  have  to  reduce  these  changes  of  increase  to  an  accumu- 
lation within  the  veins.  But  they  are  also  noticeable  in 
other  parts,  as  the  visible  effect  of  blood-transfusion,  in  the 
face,  the  conjunctiva,  the  mucous  membranes.     Within  the 


SURGICAL   EMERGENCIES.  VJ 

confines  of  the  portal  circulation  we  may  also  have,  at  a 
brusque  infusion  of  blood,  particularly  into  the  jugular 
vei»s,  a  direct  plethora  by  its  passage  through  the  liver.  The 
tenesmus  (which  now  and  then  appear  after  transfusion)  and 
even  haemorrhage  from  the  intestines  are  attributable  to 
this  same  cause.  Experiments  have  even  shown  that  in 
quick  injections  the  liver  is  lacerated  and  ruptured.* 

There  remains  the  last  possibility:  that  the  excess  of  blood 
accumulates  principally  in  the  small  vessels.  And  this  is  sup- 
ported by  several  facts. 

We  know  that  the  blood  capacity  of  the  individual  organs 
varies.  Here  psychic,  sensorial  and  sensible  reflexes,  are 
as  much  to  be  considered  direct  mechanical  influences,  ac- 
cording to  the  position  of  the  parte,  in  existing  or  absent 
muscle-contractions,  etc.  Particularly  instructive  in  this  re- 
spect are  the  changing  redness  and  pallor  of  the  skin,  then 
the  changes  of  volumes  of  the  extremities  under  different  in 
fluences,  as  they  are  demonstrated  by  the  ingenious  contri- 
vance of  Mosso  f  (plethysmograph)  and  then  particularly 
the  arrangement  of  the  corpora  spongiosa. 

There  are  consequently  within  the  organism  a  great  num- 
ber of  minor  vessels  at  disposal,  within  which  the  moderate- 
ly infused  blood  may  disseminate  itself.  Only  in  case  of  an 
immoderate  infusion  of  blood,Worm-Muller's  third  territory 
of  vascular  capacity,  a  rupture  of  the  vascular  walls,  would 
come  into  question. 

The  division  of  blood  will  differ  in  the  individual  organs 
according  to  their  capacity.  Thus  we  have  before  us  within 
the  cutis,  within  the*  muscular  vessels,  the  bone  vessels,  in 
all  mucous  membranes,  particularly  in  the  intestine,  but 
also  in  the  liver  and  spleen,  those  parts  in  which  blood-in- 
fusions make  a  hyperemia  first  visible,  corresponding  to  the 
normally  considerable  blood-capacity.  That  this  is  so,  you 
have  already  learned  from  the  experiment,  where  we  suc- 
ceeded by  the  squeezing  of  the  extremities,  the  pressure  of  bel- 
ly and  thorax,  not  only  in  increasing  the  blood-pressure,  but 
also  the  quantity  of  the  blood  from  the  carotid.  But  you 
notice  at  the  same  time  that  the  blood  accumulates  to  a  con- 


*  Casse.  De  la  Transfusion  du  sang.  Memoire  presente  a  l'Academie 
royale  de  medecine  a  Bruxelles,  le  29  Novembre,  1873,  p.  55. 

f  Mosso,  Sopra  un  nuovo  metodo  per  scrivere  i  movimenti  dei  vasi 
sanguigni  nell*  uomo.  Torino,  1875.  (cf.  Centralblatt  fur  Chirurgie,  1876. 
S.   166). 


18  SURGICAL  EMERGENCIES. 

siderable  extent  also  within  the  vessels  which  are  on  one  hand 
not  directly  subject  to  the  action  of  the  heart,  on  the  other 
hand  inaccessible  as  well  to  our  manipulations  (blood  ves- 
sels of  the  bones,  and  of  the  spinal  cord). 

What  now  becomes  of  the  infused  blood  ?  Does  the  or- 
ganism permanently  retain  the  increased  serum  and  discs 
of  the  blood  ?  Only  at  first.  For  soon  the  increased  secre- 
tion of  urine  and  urea  reduces  the  quantity  of  blood  and 
the  number  of  blood-corpuscule  to  their  normal  limit.  If  we 
infuse  not  heterogeneous  but  homogenous  blood,  so  that  no 
direct  dissolution  of  the  corpuscles  takes  place,  both  the 
blood  serum  and  the  urine  are  without  haemoglobine.  And 
the  homogeneous  but  superfluous  blood -discs  perish  within 
the  blood-mass,  as  happens  continually  with  decrepit  discs  at 
other  times  as  well.*  Thus  Valentin's  f  opinion  that  the 
organism  always  maintains  a  constant  quantity  of  blood 
in  proportion  to  the  body-weight  is  also  so  far  true  that 
within  the  blood-tissue  only  a  definite  number  of  blood-discs 
can  retain  a  permanent  vitality. 

Having  convinced  ourselves,  that  the  division  of  blood 
within  the  individual  organs  is  varying  and  that  this  be- 
comes the  more  apparent  in  copious  infusion,  we  must  en- 
quire, whether  this  peculiarity  of  blood- dispo  sit  ion  also  prevails 
with  losses  of  blood. 

Indeed  already  the  course  of  the  blood-pressure  curve  af- 
ter phlebotomy  offers  certain  points  of  support.  A  sudden 
opening  of  a  large  vascular  trunk  causes  by  the  rapid  de- 
pletion of  the  aortic  contents  an  immediate  decrease  of 
blood-pressure,  which,  however,  soon  gives  way  to  a  propor- 
tionately larger  increase,  caused  by  the  excitement  of  the 
vaso-motor  centres.  This  excitement  is  less  pronounced  in 
a  slow  loss  of  blood.  Here  the  pressure  may  keep  at  the 
normal  height,  till  about  one  half  of  the  normal  quantity  of 
blood  has  been  withdrawn  from  the  organism.  But  after 
this  the  blood  pressure  decreases  rapidly  to  the  very  lowest  point \ 
when  death  appears  after  convulsions.  This  happens  when  the 
individual  has  lost  about  5  per  cent,  of  its  body-weight  in 
blood.  Only  with  animals  made  plethoric,  have  we  noticed 
death  and  therefore  the  corresponding  decrease  of  pres- 
sure to  the  lowest  point,  while  the  organism  disposes  of  an 

*  Worm-Miiller,  Transfusion  und  Plethora.  Christiania,  1875.  Uni- 
versitatsprogramm.  S.  63. 

f  Valentin,  Lehrbuch  der  Physiol.  1847.  Bd.  I.  S.  413. 


SURGICAL  EMERGENCIES.  19 

amount  of  blood  quite  surpassing  the  normal  quantity. 
More  than  five  per  cent  of  the  body-weight  in  blood  can  by 
no  means  be  expected  to  be  drawn.  Even  in  case  of  tetan- 
zation  of  the  spinal  cord  of  animals,  no  greater  phlebotomic 
quantity  can  be  obtained,  because  in  case  of  bleeding  with 
suddenly  decreasing  blood-pressure,  a  blood  distribution  in 
the  above  mentioned  sense  takes  place  in  the  organism  in 
such  a  manner  that  a  large  quantity  of  blood  within  these 
vessels  is  not  subject  to  vaso-motor  influences. 

A  further,  practically  important  point  is  derived  from 
the  observation  of  the  blood-pressure  curve,  according  to  the 
slow  or  rapid  progress  of  the  bleeding.  Thus  we  have  seen 
that  a  rapid  blood-depletion  causes  an  increase  of  blood- 
pressure  instead  of  a  decrease,  and  would  consequently  not 
be  justified,  where  it  is  our  object  to  produce  by  blood-de- 
pletion a  decrease  of  tension  in  the  aortic  system.  At  any 
rate,  the  loss  of  blood  required  would  be  disproportionately 
great  in  comparison  with  the  object  sought. 

The  course  of  the  blood-pressure  curve  teaches  us  that  in 
slow  bleeding  the  normal  tensions  of  the  vascular  system 
may  be  retained  for  a  long  time,  till  suddenly  the  life-men- 
acing decrease  of  the  blood-pressure  makes  its  appearance. 
This  insidious  course  of  the  blood-pressure  conditions  in 
connection  with  the  suddenly  approaching  catastrophe,  is 
only  too  often  met  with  at  the  sick-bed,  and  is  caused  either 
by  repeated  haemorrhages  after  surgical  operation  or  by  that 
apparently  insignificant  continuous  puerperal  flowing  af- 
ter confinement.  Here  we  must  promptly  recognize  the 
danger  and  remove  it  before  it  is  too  late. 

The  battle-field  furnishes  the  most  important  example  of 
the  conditions  of  rapid  rise  of  blood-pressure  after  loss  of 
blood  in  gun-shot  wounds  of  the  great  vascular  trunks. 
The  rapidly  appearing  vascular  spasm  and  single,  but  co- 
pious, haemorrhage,  with  subsequent  sudden  decrease  of 
tension  in  the  aortic  system  have  been  known  for  ages  as 
an  attempt  of  nature  towards  spontaneous  haemostasis. 

The  peculiar  blood-distribution  within  the  bleeding  organ- 
ism which  exhibits  so  great  a  similarity  with  that  in  blood- 
injections,  constitutes  quite  frequently  the  cause  of  death — 
and  not  the  loss  of  blood  itself.  The  individual  does  not  per- 
ish from  want  of  blood,  but  from  want  of  motion  of  the  blood* 

*  Vergl.  auch  L.  v.  Lesser,  Transfusion  und  Autotransfusion.  Samml. 
klin.  Vottrage.  Nr.  80.  - 


26  SURGICAL  EMERGENCIES. 

But  to  these  quantitative  conditions  of  blood-distribution 
are  joined  besides  qualitative  ones  of  special  significance. 

It  is  an  old-established  fact  that  after  phlebotomy  the 
blood  becomes  more  watery  and  poorer  in  pigment.  But 
for  this  thinning  of  the  blood,  various  attempts  at  expla- 
nation have  been  made. 

It  was  claimed  chiefly  that  blood-loss  caused  tissue  juice 
and  lymph  to  flow  into  the  blood.  Later  it  was  believed, 
that  the  loss  of  red  blood-discs  directly  caused  the  paleness. 

Closer  experimental  investigation  of  these  questions  has 
shown,  that  in  rapid  bleeding  neither  the  entrance  of  serum 
nor  lymph,  nor  the  loss  of  blood-discs  directly  influences 
the  pigmental  contents  of  the  different  phlebotomic  por- 
tions. These  pigment-contents  exhibit  relations  which,  graphically 
represented,  correspond  perfectly  to  the  course  of  the  blood-pressure 
curve  venesections*  The  proportion  of  blood-corpuscles 
maintains  approximately  its  normal  measure,  to  decrease 
suddenly  after  the  loss  of  about  one  half  of  the  blood  in  the 
body.  But  while  the  blood-pressure  invariably  decreases 
until  death,  the  proportion  of  pigment  may  increase  far  be- 
yond the  normal  height  even  after  death  itself. 

Moreover,  a  number  of  other  experiments  where  no  blood- 
depletion  had  taken  place,  show  that  the  proportion  of  pig- 
ment does  not  depend  directly  on  the  loss  of  blood,  but  on 
blood-pressure  conditions.  That  the  peculiar  blood-distri- 
bution which  takes  place  is  accompanied  by  a  correspond- 
ing arrangement  of  red'blood-discs,  in  which  a  large  num- 
ber of  blood-corpuscles  are  temporarily  thrown  aside  from 
the  blood- current.  Particularly  remarkable  is  the  fact,  that 
in  individuals  who  remain  at  rest  for  a  considerable  space 
of  time,  the  proportion  of  pigment  in  the  blood  may  at 
times  decrease  far  below  the  normal  measure,  even  without 
any  loss  of  blood,  and  that  sudden  and  violent  muscular 
motions,  as  well  as  the  squeezing  of  the  extremities,  etc., 
may  increase,  again,  the  proportion  of  pigment  even  beyond 
the  normal  standard. 

Similarly  in  venesections  with  decreasing  blood-pressure, 
there  will  remain  a  larger  number  of  red  blood-discs  within 
the  vessels  whose  blood-column  is  no  longer  under  the  in- 
fluence of  the  impulse  of  the  heart. 

*  L.  v.  Lesser,  Ueber  die  Vertheilung  der  rothen  Blutscheiben  im 
Blutstrome.  Reichert  und  du  Bois' Archiv,  1878.  S.  41 — 108  in  der  physiol. 
Abth. 


SURGICAL   EMERGENCIES.  21 

For  the  present  we  shall  let  it  be  an  open  question  how 
far  chemical  material,  which  temporarily  decreases  blood- 
pressure,  may  assist  in  changing  the  blood-composition. 
(See  below.) 

Thus  the  sum  total  of  the  experimental  facts  hitherto  dis- 
cussed, has  shown  us,  first,  that  the  organism  needs  a  certain 
quantity  of  arterial  tension,  to  remain  alive;  secondly,  that 
this  tension  depends  not  so  much  on  the  absolute  quantity 
of  blood,  but  rather  on  the  distribution  of  it ;  and  thirdly 
that  this  blood-distribution  is  closely  connected  with  a 
peculiar  arrangement  of  the  blood-discs. 

What  practical  results  may  now  be  derived  from  these  facts 
for  our  instruction  on  the  subject  of  haemostasis  ? 


22  SURGICAL  EMERGENCIES. 


LECTURES  III  AND  IV. 

Hcemostasis.  —  Blood-saving.  —  Hcemostasis,  especially  of  blood 
jrotn  injured  arteries. — Progress  of  occurrences  during  the 
healing  of  arterial  wounds. — Proliferation  of  the  vascular 
walls  and  thrombus  organization. — Bruises,  cuts  and  punctures 
of  arteries. — Foreign  bodies  grazing  the  arterial  tube. — Cat- 
gut as  material  for  ligatures  and  its  action  within  the  different 
tissues. —  Thread-ligature  in  (aseptic)  wounds. — Instruments 
for  vascular  ligatures. — Ligature  of  artery  stumps  a7id  in  the 
continuity  of  the  vessels. — Substitutes  for  thread-ligature. — 
Hcemostasis  at  certain  parts  of  the  body. — Places  for  the  com- 
pression of  arterial  trunks. 

Generally  there  are  three  means  of  meeting  the  loss  of 
blood,  occasioned  by  intentional  or  unintentional  wounds, 
viz.: 

A.  The  saving  of  blood  ;  B.  The  stopping  of  blood  ;  C. 
The  compensation  for  loss  of  blood. 

We  are  indebted  to  Esmarch  *  for  methodically  perfect- 
ing the  art  of  blood-saving  during  operations,  even  though  in 
former  times  the  method  had  been  repeatedly  applied,,  par- 
ticularly in  amputations,  of  raising  the  extremities  and 
squeezing  them  out  before  beginning  the  compression  of 
the  supplying  arterial  trunk. 

Aside  from  the  direct  economizing  of  blood,  Esmarch's 
method  can  claim  the  following  additional  advantages  : 

a.  If  the  progress  of  the  wound  is  not  aseptic,  the  limited 
loss  of  blood  diminishes  the  danger  of  a  septic  infection, 
which  in  the  same  manner  as  extended  thrombi,  occurs  easier 
in  anaemic  cases  than  elsewhere.f 

b.  Fresh  wounds,  as  they  do  not  bleed,  need  not  be 
sponged  so  frequently  during  an  operation,  which  consider- 
ably lessens  irritation  ;  then 

*  Esmarch,  Ueber  Blutersparung  bei  Operationen  an  den  Extremita- 
ten.  Verh.  d.  deutschen  Gesellschaft  fur  Chirurgie.  II.  Congress.  (Sitzung 
vom  18  April,  1873). 

f  Esmarch,  Ueber  kiinstliche  Blutleere.  Verh.  d.  deutchen  Gesellschaft 
fur  Chirurgie.     III.  Congress.  (Grossere  Vortrage  Nr.  1.) 


SURGICAL   EMERGENCIES.  23 

c.  The  method  allows  operation  without  any  assistance 
whatever. 

d.  Its  simplicity  is  such  that  any  layman  may  soon  learn 
and  perform  it  independently. 

e.  The  circumscribed  compression  of  large  vascular  trunks 
is  avoided,  and  this  may  become  a  matter  of  importance, 
where  the  vascular  walls  are  liable  to  rupture. 

f.  The  method  of  blood-depletion  is  pre-eminently  applic- 
able for  the  production  of  local  anaesthesia,  by  combining 
ischaemia  with  a  congelation  of  the  parts,  either  by  an  ether- 
spray  or  by  the  aid  of  a  frigorific  mixture,  and  the  like, 
Thus  we  are  enabled  to  perform  painlessly,  even  without 
general  narcosis,  certain  operations,  as,  for  instance,  that  of 
an  ingrown  nail,*  the  incision  of  panaritiae,  even  amputa- 
tion and  resection  of  phalanges. 

g.  The  method  of  blood-depletion  of  the  parts  allows  us 
furthermore  to  apply  more  effectively  the  actual,  or  galvano- 
cautery,  than  formerly,  for  the  intensity  and  extent  of  the 
cauterization  is  much  easier  adjusted,  if  the  field  of  oper- 
ation is  not  continually  moistened  by  the  rush  of  blood. 

h.  This  method  obtains  a  special  importance  in  oper- 
ations, where  it  is  necessary  to  subject  the  affected  parts  to 
a  quick  and  close  examination,  as  in  synovitis  tuberculosa 
and  tumefactions,  in  order  to  remove  as  thoroughly  as  pos- 
sible the  affected  tissue. 

i.  Likewise  are  we  enabled  by  this  artificial  ischaemia  to 
find  easily  and  remove  any  extraneous  body,  particularly 
needles. 

k.  This  proceeding  proves  itself  important  for  the  de- 
tection of  injured  or  severed  arteries.  It  enables  us  also  to 
proceed  more  courageously,  in  the  extirpation  of  aneurisms, 
than  we  could  formerly.  The  proposition  came  from  Eng- 
land that  this  method  should  be  also  applied  in  the  direct 
treatment  of  aneurisms,  and  it  has  been  used  there  several 
times  with  excellent  results. 

/.  Finally,  this  method  will  be  met  with  in  the  subject  of 
blood-substitution  as  a  very  prompt  means  of  autotrans- 
fusion. 

To  carry  out  the  method  Esmarch  proposed  a  rubber 
bandage  of  a  certain  length  and  breadth  for  binding  the 
extremities,  and  a  thick  rubber  tube  for  circular  constric- 

*  Girard,  Zur  Erleichterung  der  Localanasthesie.  Centralblatt  fur 
Chirurgie.  1874.   Nr.  2. 


24  SURGICAL  EMERGENCIES. 

tion  of  the  extremities  above  the  rubber  bandage.  The 
rubber  bandage  must  be  so  applied  that  we  first  unroll  an 
extra  portion  which  is  to  hang  out,  before  the  bandaging 
either  of  hands  or  toes  commences,  and  that  we  draw  the 
bandage  only  so  tight  that  it  evenly  envelopes  the  extremity, 
and  at  the  same  time  lightly  compresses  it,  without  exerting 
on  any  one  place  a  stronger  local  pressure.  It  has  been 
recommended  to  use  instead  of  the  rubber  tube,  which  by 
too  tight  pulling  may  easily  act  injuriously,  pieces  of  strong 
woven  rubber  bands  with  clamps  or  hooks.  It  seems  sim- 
plest to  wind  around  the  last  piece  of  the  band  in  several 
turns  over  one  another,  for  the  purpose  of  constriction, 
and  to  fasten  these  twists  securely  and  permanently  by  a 
clamp  that  may  be  screwed  together  and  pushed  under.  It 
is  only  for  the  shoulder  and  hip  joints  that  this  contrivance 
for  constriction  is  fastened  somewhat  differently.  For  the 
shoulder  joint  we  formerly  made  a  recumbent  figure  of  8, 
crossing  the  two  parts  of  the  tube,  on  top  of  the  shoul- 
der, while  the  ends  were  tied  in  the  armpit  of  the  opposite 
side.  The  hindrance  to  respiration  makes  it  desirable  to 
change  this  arrangement;  we  therefore  let  our  assistant 
hold  down  with  the  palm  of  his  hand  the  two  parts  of  the 
tube  at  the  point  of  intersection  on  top  of  the  shoulder  and 
to  prevent  its  slipping  we  fasten  a  strip  either  across  the 
chest  or  the  back,  which  pulls  in  the  direction  of  the  other 
armpit. 

A  hip  constriction  of  the  upper  thigh  can  only  be  obtained 
by  guiding  the  tube  around  the  root  of  the  leg  from  the 
rear,  crossing  the  two  parts  in  front  above  the  femoral 
artery,  i.e.,  the  centre  of  Poupart's  ligament,  and  twisting 
the  ends  around  the  pelvis,  tying  them  again  in  front.  In 
order  to  obtain  an  energetic  compression  it  is  advisable  to 
insert  below  the  crossing  point  of  the  two  parts,  above  the 
Ligamentum  Poupartii,  a  roll  or  bandage. 

In  operations  in  the  locality  of  the  hip-joint  itself,  particu- 
larly for  the  exarticulation  of  the  upper  thigh,  this  method 
of  blood-depletion  does  not  prove  sufficient.  Here  the 
direct  compression  of  the  aorta  claims  its  right.  This  is 
most  frequently  made  in  the  direction  from  the  abdomen 
(of  course  after  thorough  depletion  of  the  intestines)  by  aid 
of  the  hands,  or,  better  yet,  by  aid  of  spinal  compressors 
(Esmarch,  III.  Chir.  Congress.  II.  Page  7).  But  sometimes  it 
may  be  made  in  the  direction  from  the  rectum,  perhaps  best 
after  its  forced  dilatation  and  insertion  of  the  whole  hand. 


SURGICAL  EMERGENCIES.  25 

The  chief  objection  to  the  use  of  rubber  bands  for  wrap- 
ping after  Esmarch's  method  is  the  perishableness  of  the 
material  ;  particularly  does  this  objection  hold  good  for 
war  purposes.  It  has  therefore  been  proposed  to  substi- 
tute a  well- woven  linen  bandage  for  the  rubber  band  (Bar- 
deleben)  and  to  use  instead  of  the  constriction-tube  simply 
as  heretofore  a  gag-tourniquet  without  pelotte,  such  as  is 
found  in  every  military  surgeon's  case.* 

Among  other  results  of  Esmarch's  method  we  have  the 
constriction  of  an  extremity  of  the  sound  side  of  a  body, 
to  dam  up  the  blood  there,  while  an  operation  is  performed 
on  the  other  leg.  If  the  loss  of  blood  should  have  been  too 
copious  that  accumulated  in  the  sound  leg  is  furnished  to 
the  heart  by  loosening  the  constriction  and  raising  the  ex- 
tremity (Bellf).  Any  elastic  band  (a  pair  of  suspenders) 
may  serve  as  a  constriction-tube  in  case  of  need. 

Another  disadvantage  of  Esmarch's  method  is  the  paraly- 
sis of  the  vascular  walls  within  the  extremity  excluded  from 
blood  circulation  for  a  length  of  time.  The  bleeding  which 
occurs  after  loosening  the  constriction  maybe  so  copious  as 
to  outweigh  completely  the  amount  of  blood  saved  during 
the  operation.  It  is,  therefore,  principally  important  to  close 
before  loosening  the  constriction  all  vascular  openings  and 
to  clasp  all  yet  bleeding  points  with  catch-forceps,  of  which 
a  great  number  must  be  in  readiness.  Where  we  need  not 
expect  a  bleeding  from  larger  vessels,  as  in  sequestrotomy 
or  in  scraping  out  an  articular  cavity,  etc.,  the  antiseptic 
dressing  may  be  put  on,  and  tight  at  that,  before  loosening 
the  constriction.  But  we  must  carefully  watch  it;  change  it 
immediately  if  blood  penetrates  it,  at  any  rate  after  twenty- 
four  hours.  The  advice  is  also  important,  to  let  the  com- 
pression of  the  supplying  arterial  trunk  continue  a  consid- 
erable length  of  time  after  detachment  of  the  tube.  The 
second  proposition  lately  made  by  Konig  J  is  to  keep  the 
extremity  raised  not  only  during  the  application  of  the  dress- 
ing, but  also  a  considerable  time  after  the  operation.  Among 
the  other  means  of  reducing  the  loss  of  blood  to  the  lowest 

*  KShler,  Die  blutsparende  Methode  im  Felde.  Deutsche  Militararztl. 
Zeitschrif,  1877.   Heft  8  u.  9.  S.  371-381. 

f  Bell,  Note  on  a  mode  of  saving  blood  in  great  operations.  (Edinb. 
Med.  Journal,  1877.  Vol.  2,  p.  141.) 

%  Konig,  Ueber  die  Vortheile  der  Verbindung  der  verticalen  Suspen- 
sion mit  dem  Esmarch's  chen  Verfahren  zum  Zwecke  der  Erzielung  blut- 
loser  Operation.     Centralblatt  fiir  Chirurgie,  1879.    S.  537* 


26  SURGICAL  EMERGENCIES. 

quantity,  after  Esmarch's  constriction,  we  may  mention  the 
tampon  with  antiseptic  (hot)  sponges  and  the  application  of 
the  electric  current. 

I.  Stopping  bleeding  from  (A)  arteries. 

As  a  type  of  the  occurrences  taking  place  in  injuries  to 
arteries,  the  spontaneous  stopping  of  blood  may  serve  us, 
which  sometimes  (tearing  off  of  an  extremity  by  a  piece  of 
bombshell)  may  be  observed  even  in  very  large  trunks. 

We  have  to  consider  here,  first,  the  lacerated  and  ragged 
condition  of  the  vascular  tissues,  then  the  elastic  retraction  of 
the  severed  vascular  tube,  and  finally  the  blood  coagulation, 
i.e.,  thrombus  formation,  within  the  injured  portion  of  the 
artery.  In  the  historical  development  of  the  search  for 
means  of  haemostasis  from  arteries,  greater  importance  has 
now  been  given  to  thrombus  formation,  and  then  again  to 
the  direct  fibrination  and  agglutination  of  the  vascular  walls. 
In  connection  with  this  we  find,  also,  now  one  kind  of  thera- 
peutic propositions,  now  another,  principally  recommended 
and  applied. 

In  winding  a  thread  about  an  artery-tube,  the  primary 
stoppage  of  blood  is  caused  by  the  tearing  of  the  interior 
and  central  vessel  coats  which  roll  up  inwardly.  At  the 
place  of  ligature,  more  powerfully  toward  the  centre  than 
the  periphery,  a  blood-coagulation  gradually  occurs,the  place 
of  which  is  after  awhile  taken  by  a  cicatrix,  which  coalesces 
with  the  proliferation  of  the  connective  tissue  proceeding 
from  the  severed  vascular  tube,  and  prevents  the  exit  of  the 
blood-wave. 

The  so-called  organization  of  the  thrombus  was  ascribed 
by  some  to  the  penetration  of  cells  from  the  blood  into  the 
thrombus.*  Others  maintained  that  at  the  closing  of  the 
vascular  tube  the  thrombus  lost  all  importance,  and  laid  the 
chief  stress  on  the  proliferation  of  the  cells  of  the  intima 
endothelium  and  the  consequent  displacement  of  the  vascu- 
lar lumen,  f  To-day  we  know,  principally  from  the  experi- 
ments of  Senftleben  J  that  the  organization  of  the  thrombus 
does  not  proceed  from  the  blood,  but  that  the  latter  is  per- 

*  C.  O.  Weber,  Handb.  der  Chir.  von  Pitha  und  Billroth,  1865.  Bd. 
I.   1.  Abth.  S.  139  u.  f. 

f  Baumgarten,  Die  sog.  Organization  des  Thrombus.  Leipzig,  1877, 
und  Raab,  Ueber  die  Entwicklung  der  Narbe  im  Blutgefass  naofc  der 
Unterbindung.     Arch  f.  klin.  Chir  Bd.  XXIII.     Heft  2.  S.  156. 

\  Senftleben,  Ueber  den  Verschluss  der  Blutgefasse  nach  der  Unterbinv 
dung.  Virchow's  Archiv,  1879.  Bd.  77. 


SURGICAL  EMERGENCIES.  27 

meated  by  cells,  which  penetrate  from  the  vasa  vasorum 
through  the  vascular  walls  into  the  thrombus,  become  fixed 
there  as  cells  of  the  newly  formed  young  connective  tissue, 
while  the  substance  of  the  thrombus  itself  becomes  subject 
to  resorption.  At  the  same  time  with  this,  direct  agglu- 
tination of  the  intima-fold  doubtless  occurs,  as  we  have 
learned  by  the  experiments  of  Baumgarten  and  Raab. 

These  healing  processes  of  injured  arteries  undergo  cer- 
tain modifications  according  to  the  nature  of  the  injury. 
Bruises  and  contusions  of  an  artery  correspond  nearest  with 
the  nature  of  a  ligature.  Thus  we  saw,  for  instance,  when 
extremities  were  crushed  or  torn  off  by  heavy  shots,  how 
very  frequently  a  spontaneous  blood-stoppage  of  even  large 
vessel-trunks,  as  that  of  the  subclavian  or  femoral  artery,  oc- 
curred. 

In  punctured  wounds,  which  decrease  in  frequency  in  war, 
but  increase  among  certain  classes  of  people,  in  peace,  a 
parietal  thrombus  arises  primarily  at  the  place  of  injury, 
subsequently  out  of  this  a  cicatrix  of  connective  tissue, 
which,  gradually  yielding  to  the  blood-wave,  causes  the  for- 
mation of  an  aneurismal  dilatation  of  the  vascular  tube,  or  if 
the  puncture  affects  besides  the  artery  the  contiguous  vein 
as  well,  or  vice  versa,  both  the  arterial  and  the  venous  wound 
may  agglutinate.  The  arterial  blood  flows  over  directly 
into  the  vein  amidst  the  varicose  enlargement  of  the  peri- 
pheral venous  net.  Thus  arises  the  varix  anewysifiaticus,  as 
it  has  often  been  observed  after  phlebotomy  in  the  bend  of 
the  elbow  with  accompanying  injury  of  the  arteria  brach- 
ialis. 

We  shall  speak  below  more  exhaustively  on  punctures 
which  penetrate  the  arterial  tube,  and  hence  injure  it  in  two 
spots. 

Different  conditions  obtain  with  sabre-wounds.  If  these 
are  made  obliquely  in  one  part  of  the  arterial  tube,  the  diag- 
onal slit  will  be  drawn  asunder  by  the  elastic  fibres,  at  work 
in  the  longitudinal  axis  of  the  tube,  into  a  roundish  opening, 
where  the  obliquely  arranged  orbicularis  muscles  are  unable 
to  cause  either  a  peripheral  or  a  central  constriction  of  the 
arterial  opening.  In  such  cases  we  must  complete  the  diago- 
nal separation  and  ligate  the  two  ends  of  the  vascular  tube. 
Where,  for  instance,  a  ball  in  its  track  grazed  an  artery, 
without  directly  injuring  the  vascular  wall,  it  is  best  to  put 
a  ligature  as  soon  as  possible  on  both  sides  of  the  grazed 
point.     For  mortification  and  desquamation  of  the  grazed 


28  SURGICAL  EMERGENCIES. 

wall  may  subsequently  take  place  with  fatal  secondary  haem- 
orrhage. These  considerations  also  lead  us  to  remove  as 
soon  as  possible  all  extraneous  bodies,  in  cases  where  balls 
lie  in  proximity  to  vascular  tubes,  or  where  bone  splinters 
with  sharp  edges  pierce  the  vascular  wall.  Similar  meas- 
ures are  requisite  in  complicated  fractures,  where  a  large 
vascular  trunk  is  threatened  by  bone  splinters,  and  here  as 
well,  we  must  give  preference  to  primary  ligature  at  the  in- 
jured spot,  to  the  less  safe  ligature  in  continuity  in  case 
of  secondary  haemorrhage. 

So  we  see  that  in  all  arterial  injuries  the  safest  means 
against  primary  and  secondary  haemorrhages  consists  in  ligature  if 
possible  011  both  sides  of  the  injured  spot  of  the  vascular  wall.  And 
this  principle  is  entitled  to  the  greatest  consideration;  in- 
deed we  may  say  that  it  has  obtained  an  unshakable,  universal 
validity  since  the  introduction  of  the  antiseptic  treatment  of 
wounds,  and  since  we  have  obtained  an  almost  ideal  mate- 
rial for  ligature  in  the  carbolized  catgut.  In  comparison 
with  this,  the  questions  whether  the  blood  stoppage  is  due 
to  thrombus  or  to  the  proliferation  of  the  vascular  wall,  lose 
their  significance,  as  the  catgut  does  not  sever  the  arterial 
tube,  but  furnishes  a  cicatricial  ring  at  the  spot  of  ligation, 
which  thickens  the  vascular  wall. 

Lister*  himself  has  first  shown  how  the  carbolized  cat- 
gut heals  in,  as  it  were.  He  thought  that  it  changed  into  a 
ring  of  living  tissue.  Several  subsequent  investigators 
have  confirmed  Lister's  statements,  but  have  not  been  able 
to  establish  that  the  catgut  continues  to  exist  at  the  place 
of  ligation  after  a  shorter  or  longer  period  of  time.  The 
assumption  that  the  lifeless  gut  should  be  changed  into  a 
living  ring  of  tissue  also  causes  a  certain  confusion. 

Though  it  was  to  be  expected  that  in  the  aseptic  progress 
of  the  wound  the  catgut  ligature  after  healing  into  the  tis- 
sue, could  not  act  otherwise  than  blood  extravasations  sub- 
ject to  resorption,  dead  bone  splinters,  etc.,  under  similar 
conditions  of  wound-healing,  yet  it  was  of  importance  to 
establish  by  experiments,  how  long  the  catgut  remains  as 
such  within  the  tissue  and  in  what  way  its  transformation 
into  stable  connective  tissue  comes  about.  As  we  often 
meet  difficulties  in  completing  the  antiseptic  treatment  of 
wounds  with  vascular  ligatures  in  animals,  I  preferred  to 

*  Lister,  Observations  on  ligature  of  arteries  on  the  antiseptic  system, 
{The Lancet,  1869.  April  3.) 


SURGICAL  EMERGENCIES.  29 

demonstrate  the  action  of  catgut  within  the  different  tissues 
and  organs  in  another  way,  namely,  by  complete  subcutaneous 
puncture,  the  skin  having  been  slided  to  07ie  side*  I  inserted 
pieces  of  catgut  under  the  skin  of  rabbits  on  different  parts 
of  the  body,  other  pieces  I  introduced  by  means  of  a  silver 
needle  obliquely  through  the  thorax,  and  in  different  direc- 
tions through  the  abdominal  cavity,  and  was  thus  enabled 
to  let  the  catgut  remain  within  the  different  tissues  any 
length  of  time  I  pleased.  The  result  was:  (1)  That  the  cat- 
gut is  to  be  recognized  as  such  much  longer  than  was  usu- 
ally supposed.  (2)  That  the  gut  becomes  subject  to  resorp- 
tion quickest  on  those  spots  where  it  is  exposed  to  pressure 
or  traction. 

(3)  That  an  immigration  of  cells  into  the  catgut  takes 
place,  proceeding  from  the  periphery.  These  cells,  which, 
at  first  singly,  then  in  radial  groups,  penetrate  the  inner 
parts  of  the  catgut,  crumble  it,  and  gradually  bring 
about  a  substitution  of  it  by  young  connective  tissue, 
which  in  time  metamorphoses  into  a  cicatricial  mass  nearly 
resembling  the  original  catgut;  in  shape  and  appearance. 
With  all  this,  it  once  happened  that  the  catgut  was  trace- 
able as  such  without  much  change  of  texture  on  the  61st 
day  after  its  subcutaneous  insertion.  In  other  cases  we 
found  it  thoroughly  permeated  by  cells  after  32  and  36 
days,  or  even  changed  into  a  cylindrical  mass  of  young 
connective  tissue.  But  even  on  the  95th  day  after  insertion 
the  then  cicatricial  mass  was  plainly  distinguishable  from 
its  surroundings.  Similar  results  were  obtained  with  cer- 
tain modifications  by  insertion  of  the  catgut  into  the  belly 
of  muscles  and  into  joints,  by  subperiosteal  entwining  of 
bones,  by  lacing  of  the  trachea  with  catgut.  A  similar  ap- 
pearance was  presented  by  pieces  of  catgut,  which  by 
puncture  of  the  abdominal  cavity  or  the  thoracic  space,  had 
been  deposited  either  in  the  lungs  or  the  myocardium,  the 
liver,  the  kidneys,  or  near  the  intestine  or  the  bladder.  In 
these  cases  it  was  noticeable  that  on  the  edge,  where  the 
catgut  freely  penetrated  into  the  intestinal  lumen  or  the 
vesical  cavity,  it  appeared  looser,  more  lacerable,  the  chan- 
nel of  the  puncture  likewise  eroded,  which  perfectly  cor- 
responds to  the  appearance  of  the  channels  of  skin  punc- 
ture by  the  use  of  catgut  for  sutures. 

*  L.  v.  Lesser,   Ueber  das  Verhalten  des  Catgut  im  Organismus  und 
Ciber   Heteroplastic     Druckfertiges  Manuscript. 


30  SURGICAL   EMERGENCIES. 

The  dissolution  of  the  catgut  takes  place  more  rapidly 
when  the  progress  is  not  purely  aseptic;  quickest  in  places 
where  unmistakable  decomposition  exists,  as,  for  instance, 
in  those  experiments  where  catgut  had  been  inserted  into 
festering  channels  or  fistulse.*  Here  catgut  acts  as 
every  other  dead  organic  matter,  as  mortified  sinew  scraps, 
muscle  portions  or  necrotic  connective  tissue.  Therefore 
no  conclusions  can  be  arrived  at  from  these  or  similar  ex- 
periments for  the  adaptability  of  catgut  for  ligatures.  But 
where  we  are  able  to  cause  the  catgut  to  heal  in  taking 
antiseptic  cautions»in  the  above-described  manner,  it  offers 
for  surgical  technique  results  hitherto  unattained. 

Furthermore,  where  the  ligature  thread  lay  in  the  wound 
as  an  extraneous  body,  saturated  with  wound-secretions, 
and  had  to  be  expelled  after  separation  of  the  vascular 
wall,  dangers  of  various  kinds  to  the  progress  of  the  wound 
had  to  be  considered — primary  haemorrhages  when  the 
ligature  was  severed  too  quickly,  secondary  haemorrhages 
when  the  wound  suppurated  on  the  fifth  or  sixth  day  after 
operation,  when  the  fluid,  saturating  the  ligature  thread, 
decomposed  and  communicating  the  decomposition  to  the 
vascular  wall,  caused  an  erosion  of  the  latter  and  a  dis- 
integration of  the  thrombus.  But  the  danger  of  a  wound- 
decomposition  was  increased  in  proportion  to  the  quantity 
of  ligature  material  accumulated  in  the  wound.  Hence 
the  endeavor  to  have  as  few  ligations  of  a  wound  as  pos- 
sible ;  hence  an  incomplete  blood-stoppage  and  in  conse- 
quence of  this  the  frequent  direct  secondary  haemorrhages. 
Another  result  of  the  above-mentioned  calamities  was 
numerous  propositions  to  create  substitutes  for  ligature, 
and  these  propositions  furnished  an  unpleasant  picture  of 
bickerings  and  petty-mindedness,  and  which  propositions 
were  as  a  rule  really  more  crude,  injurious,  and  more  com- 
plicated than  the  thread-ligature  itself. 

But  even  in  the  further  stages  of  the  wound  progress  a 
new  danger  arose  on  account  of  the  slowness  of  expulsion 
of  the  thread,  namely,  the  so-called  ulterior  secondary 
haemorrhages.  These  were  caused  either  by  the  fact  that 
the  thread  had  cut  through  the  vascular  lumen  deeper  on 
one  side  than  on  others  (arterial  fistules),  or  by  the  incom- 
pleteness of  the  thrombus  formation,  when  the  thread  had 

r 

*  P.  Brans,  Die  temporare  Ligatur  der  Arterien  u.  s.  f.  Deutsche 
Zeitschr.    f.  Chir.  1875.    Bd.  V.  S.  69  (des  Sep.-Abdr.) 


SURGICAL  EMERGENCIES.  3 1 

been  wound  around  too  closely  beneath  a  large  lateral 
branch.  Hence  the  rule  to  place  the  ligature  always  above 
a  large  lateral  branch.  But  this  very  rule  proves  itself 
almost  illusory  in  several  very  important  places  of  ligation 
on  account  of  the  large  number  of  radiating  lateral  branches 
(arteria  subclavia.)  This  rule  proved  unsuitable  to  a  still 
higher  degree  in  injuries  to  a  vascular  trunk  in  any  part  of 
its  course,  than  it  was  for  the  theory  of  ligature  in  con- 
tinuity. In  those  cases  it  often  became  necessary  to  expose 
the  vessel  beyond  the  starting-point  of  the  next  higher 
lateral  branch,  and  this  made  the  procedure  cause  much 
injury.  As  now  the  catgut  does  not  cut  through  the 
vascular  trunk,  but,  so  to  speak,  forms  around  it  at  the  place 
of  ligature  a  strengthening  ring,  it  is  immaterial,  where  the 
arterial  wound  is  and  at  what  place  we  place  the  c^'qrut 
around  the  artery. 

But  catgut  has  also  certain  faults,  to  judge  by  the  a'xve- 
mentioned  results  of  our  experiments  as  well  as  by  prac- 
tical experiences.  It  cannot  fulfill  its  task  where  it  is  ex- 
posed to  too  powerful  a  pressure  and  traction,  or  where  there 
is  too  rapid  disintegration  of  the  catgut,  as,  for  instance, 
within  the  abdominal  cavity.  (This  happens  here,  com- 
pared with  other  places,  probably  on  account  of  the  ab- 
normally large  quantity  of  fluid  and  the  frequently  imper- 
fect aseptic  progress  of  the  wound.)  Catgut  seems  for  the 
above  reasons  also  unsuitable  for  relaxation  sutures  on  the 
skin  surface  in  plastic  operations,  for  muscle-sutures 
(suture  of  the  abdominal  after  laparotomy)  for  uterus- 
suture  after  hysterotomy  and  for  pedicle-ligature  after 
ovariotomy.  Here  we  are  compelled  to  use  substitutes,  such 
as  silver-thread  for  use  on  the  skin  surface,  or  for  sutures 
and  ligatures  below  the  surface,  silk  of  various  thicknesses, 
which  has  been  previously  boiled  in  a  five-per-cent  solu- 
tion of  carboUc  acid  and  kept  there  for  some  time 
(Czerny*). 

It  only  remains  now  to  mention  the  ligature  material 
formerly  in  use  or  still  applicable.  Thus  sea-weed,  being  a 
substance  which  causes  very  little  irritation,  has  proved 
serviceable,  particularly  for  sutures.  Also  horse-hair, 
thoroughly  cleansed  and  delubricated  has  been  proven  to 
cause  but  little  irritation.     Lately  braids  of  prepared  horse- 

*  Czerny,  Studien  zur  Radicalbehandlung  der  Hernien.     Wiener  med. 

Wochensshrift,  1877.     Nr.   21-24. 


32  SURGICAL   EMERGENCIES. 

hair  have  even  been  used  by  Lister  as  capillary  drains  instead 
of  rubber  tubes  for  the  same  purpose.  We  shall  keep  this 
great  applicability  of  horse-hair  in  view  with  reference  par- 
ticularly to  military  surgery. 

Besides  raw  Chinese  silk,  recommended  by  Astley  Cooper 
and  Simon,  which  we  now  exclusively  prepare  after  Czerny's 
method,  Spencer  Wells  has  found  thick  hemp-threads  par- 
ticularly suitable  for  ligature  of  the  ovarian  pedicle. 
Common  thread,  saturated  with  carbolic  acid,  may  also  be 
used  in  case  of  need.  In  rare  cases  use  is  made  of  English 
silkworm-gut  on  account  of  its  resistency  and  its  incapacity 
for  imbibition,  which  is  used  on  English  fishing  tackle  for 
suspending  the  hook. 

For  the  introduction  of  silver  among  metal  threads,  we 
are  indebted  to  Marion  Sims  (1857),  who  first  used  it  in  an 
original  manner  for  relaxation  sutures.  Two  years  later 
Simpson  tried  to  introduce  iron  ;  while  we  mention  Diffen- 
bach's  lead-threads  for  staphyloraphy  only  as  of  historical 
interest. 

To  apply  a  ligature  to  an  injured  or  completely  bisected, 
or  even  intact,  artery,  we  need,  besides  the  material,  only  a 
very  slight  apparatus.  We  shall  need  a'  sharp-pointed 
hollow  scalpel,  where  the  tissues  must  be  cut  through  as 
far  as  the  vessel.  Where  the  injured  vessel  lies  deep  in  the 
passage  of  a  ball  or  between  splinters  of  a  complicated 
fracture,  we  shall  need  a  hernia-knife  for  dilatation  of  the 
skin  and  muscle  wound  and  for  the  inclovation  of  fascial 
fissures,  in  order  to  lay  the  injured  artery  bare  with  accuracy, 
and  to  be  able  to  examine  it  in  all  directions,  and  to  cut  out 
eventually  the  injured  part  of  the  vessel.  (Rose's  *  blood- 
less extirpation  of  arterial  punctures).  A  free-hand  cut 
reaching  the  subcutaneous  connective  tissue  must  be  made 
to  sever  the  uninjured  skin,  after  having  determined  the 
exact  position  of  the  artery  to  be  exposed.  The  edges  of 
the  cut  must  be  smooth  and  the  skin  must  be  incised  in 
its  entire  thickness  from  point  to  point  of  the  wound.  The 
incision  of  the  lower  strata,  the  fasciae,  the  perimysia  and 
even  of  the  vascular  sheaths  must  be  made  in  the  following 
manner  :  By  the  aid  of  two  hooked  forceps,  of  which  the 
operator  holds  one  with  his  left  hand,  while  the  assistant 
holds  the  other,  we  raise  the  layer,  in  which   the  incision  is 

*  Rose,  Ueber  Stichwunden  der  Oberschenkelgefasse  und  ihre  sicherste 
Behandlung.     Sammlung  klinischer  Vortrage.  Nr.  92, 


SURGICAL  EMERGENCIES.  33 

to  be  made,  in  a  fold,  occupying  an  oblique  direction  to 
the  cut,  and  carefully  make  the  incision.  Thus  the  injury 
of  the  vessels  is  the  least,  the  hemorrhage  reduced  to  its 
minimum,  an  injury  of  the  larger  vessels  impossible,  which, 
in  former  operations  with  the  director  very  frequently 
happened.  We  regret  the  use  of  the  director,  because  it 
yields  exactly  the  reverse  of  the  advantages  derived  from 
incision  between  two  pairs  of  forceps. 

Having  reached  the  vascular  sheath  we  open  it  carefully 
to  a  short  extent,  isolate  the  vascular  tube  within  its  sheath 
by  blunt  hooks  which  are  curved  either  at  the  edge  (Cooper, 
Grafe)  or  on  the  surface  (Lang,  Rust).     Deschamps'  needle, 
bent  at  right    angles,  also  belongs   here.     These  so-called 
artery  hooks  have  an  eye  at  the  point,  guiding  the  thread 
which  is  to  be  wound  around  the  arterial  tube.     But  such 
a  hook  can   be  easily  improvised  out  of  any  pliable  probe 
with  an  eye  or  out  of  a  strong  curved  sewing-needle,  whose 
sharp   point  is  held  by  a  ligature  forceps;  and,   indeed,  in 
emergencies,  when   the  necessary  instruments  are  lacking, 
we  might  even  use  our  finger  for  pressing  apart  the  soft 
parts  and  isolating  the   vascular  tube.     Vessels  completely 
severed  are  seized  with  special  artery  forceps.     These  differ 
from  each  other  by  the  shape  of  their  branches,  which  take 
hold,  and  by  their  manner  of  locking.     The  forceps  with 
movable    lock  (Schmucker,    Fricke,    Amussat)    cannot  be 
recommended  as   highly,  on  account    of  the    difficulty  of 
cleaning  them,  as  those  with  a  spring  lock  and  with  bulging 
blades,  which  terminate  conically.     The  bulging  shape  is 
therefore  preferable,  because  it  is  impossible  to  tie  up  the 
ends  of  the  forceps  with  the  loop  of  thread  meant  for  the 
ligature.     But  such    tying  up   happens  all  the  easier,  the 
deeper  the  artery  lies  which  we  wish  to  grasp  with    our 
forceps.     This    was   the    reason    why    they   formerly    con- 
structed special  forceps  for  deep  ligature  (Luer,  Mathieu). 
Our  object  is  easiest  obtained  by  seizing  the  artery-stump 
with  two  forceps  Hear  each  other.     It  is  impossible  to  tie 
up  the  points  of  two  forceps.     (Hamilton's  bull  dog  forceps 
are  by  far  the  best  form  to  use.)     Formerly  they  also  used 
for   seizing  and    pulling   out  vessels  sharp  curved  hooks, 
(Fabricius  Hildanus,  Bromfield;  Sextor's  hooks  with  point- 
covers)  ; 

The  ligature  of  the  ends  of  completely  severed  vessels 
happens  most  frequently  ; 

(i)  With  amputation  stumps  as  Ambroise  Pare  (i509_I59°) 


34  SURGICAL  EMERGENCIES. 

is  said  to  have  applied  extensively  during  his    campaign 
under  King  Francis  I. 
(2)  With  wounds,  viz.: 

a.  Operation-wounds. 

b.  Wounds  within  complicated  bone-fractures. 

The  already  mentioned  artery-punctures  deserve  special 
mention.  There  danger  lies  in  their  frequent  and  ap- 
parently enigmatical  secondary  haemorrhages. 

With  these  we  can  least  of  all  rely  on  a  simple  compress 
bandage.  It  is  necessary  to  proceed  from  the  very  outset 
thoroughly  and  radically  to  prevent  the  injuries  by  the 
steadily  re-occurring  losses  of  blood,  which  are  followed 
by  a  life-endangering  exhaustion.  The  patient  being 
chloroformed,  we  dilate  to  the  required  extent  the  channel 
of  the  puncture  in  the  soft  parts — and  withal  as  deep  as 
possible,  close  to  the  injured  blood-vessel,  from  which  a  pow- 
erful blood-wave  rushes  forth,  continually  inundating  the 
entire  cavity  of  the  wound.  Here  we  must  be  quick.  The 
operator  forthwith  inserts  his  right  index  into  the  wound 
to  find  by  the  touch  of  his  finger-tip  the  opening  of  the 
artery  and  to  stop  it  up.  Now  the  bleeding  ceases.  After 
removal  of  every  thrombus  we  continue  to  open  the  soft 
parts  farther  around  the  index,  till  the  vessel  above  and 
below  the  point  of  injury  may  be  fully  isolated.  Now  the 
assistant  winds,  centrally  and  peripherally,,  from  the  obtura- 
ting fingertip,  a  thread  around  the  vascular  tube.  One 
would  think  the  haemostasis  would  be  definite  and  yet  such 
need  not  be  the  case.  It  may  be  that  between  the  two 
ligatures  at  the  wall  opposite  to  the  puncture  a  vascular 
arm  branches  off,  out  of  which  a  secondary  hemorrhage 
may  issue  at  the  restitution  of  the  collateral  circulation. 

That,  indeed,  the  restoration  of  the  collateral  circulation 
takes  place  very  rapidly,  even  in  large  vessels,  such  as  the 
femoral,  is  beautifully  shown  by  the  experiments  of  Son- 
nenberg  and  Tiegel,*  who  were  able  to  observe  in  the 
ligation  of  the  aorta  a  considerable  rise  of  pressure  but  a 
short  time  after  the  ligation,  by  means  of  the  manometer, 
which  had  been  attached  to  the  femoral  both  centrally  and 
peripherally.  Similar  observations  in  man  were  made  by 
Neudorfer  &  Kocher.f 

*  Sonnenberg  und  Tiegel,  Einige  Bemerkungen  betreffend  die  Herstel- 
lung  des  Collateralkreislaufes  u.  s.  f.  Centralblatt  f.  Chir.  1876.  Nr.  44. 
S.  689. 

f  Kocher,  Beitrag  zur  Unterbindung  der  Art.  fem.  comm.  v.  Langenb. 
Archiv,  1869.  Bd.  XL  S.  _537*~ 


SURGICAL   EMERGENCIES.  35 

Or  the  puncturing  instrument,  which  has  entered  ob- 
liquely to  the  longitudinal  axis  of  the  artery,  has  touched 
not  only  the  front  wall  of  the  vessel  but  also  the  hind  wall, 
but  much  higher  either  upward  or  downward,  so  that  the 
puncture  occupies  a  position  either  above  the  central  or 
beneath  the  peripheral  ligature.  Here  as  well  secondary 
haemorrhage  may  occur  with  the  same  degree  of  danger  as 
if  nothing  had  been  done  by  the  surgeon.  Therefore  Rose's 
proposition,  to  isolate  the  arterial  puncture  totally,  to  bind 
all  affluent  vessels  separately  and  extirpate  them  after 
securing  the  arterial  tube  centrally  and  peripherally,  is 
worthy  of  the  highest  consideration. 

The  ligature  of  arteries  in  continuity  is  applied — 1.  in 
the  treatment  of  aneurisms  (after  Antyllus,  Hunter,  Bras- 
dor  and  Wardrop),  also  in  the  extirpation  of  aneurisms. 

2.  As  a  preparatory  act  for  greater  operations  to  avoid 
considerable  losses  of  blood,  either  in  case  of  difficulties 
having  arisen  in  the  timely  securing  of  large  vessels,  or  in 
case  of  extirpation  of  tumors  of  very  large  size  and  con- 
taining a  large  amount  of  blood.  Ligation  of  the  lingualis 
before  tongue  extirpation — ligation  of  the  subclavian  in 
large  mammal  tumors  with  high  infiltration  of  the  axillary 
glands — ligation  of  the  axillary  in  exarticulation  of  the 
shoulder  on  account  of  large  swelling  of  the  head  of  the 
humerus, ligation  of  the  femoral  in  exarticulation  of  the  thigh. 

3.  In  bleeding  from  artery  wounds,  as  central  ligature; 
formerly,  however,  recommended  unjustifiably  often.  The 
most  striking  proof  of  the  uncertainty  of  the  procedure  is 
furnished  by  the  history  of  many  cases,  in  which  several 
ligatures,  approaching  closer  and  closer  the  heart  have 
proved  fruitless.  Particularly  since  we  have  been  enabled 
by  Esmarch's  method  to  empty  the  parts  of  blood  and  to 
have  an  unimpeded  and  plain  view  of  the  injured  vessels 
within  them,  we  can  set  up  the  general  and  incontrovertible 
principle  that  in  all  artery  wounds  the  sovereign  means  of 
hozmo  stasis  consists  in  antiseptic  thread-ligature  at  the  very  poi?it 
of  injury. 

If  in  spite  of  this,  we  devote  a  few  remarks  to  substitutes 
for  the  ligature,  we  do  so,  because  the  kind  and  manner  of 
haemostasis  is  determined  in  certain  cases  by  the  topo- 
graphical conditions  of  the  bleeding  part.  Again,  a  few 
of  the  methods  about  to  be  mentioned  have  acquired  a 
lasting  citizenship  in  operative  technique,  so  that  we  can- 
not pass  them  by  in  silence. 


36  SURGICAL   EMERGENCIES. 

We  divide  the  substitutes  for  ligature  into  provisory,  i.e., 
such  as  are  to  prevent  the  loss  of  blood  till  a  ligature  per- 
forms this  function;  and  permanent,  i.e.,  such  as  have 
been  recommended  and  introduced  to  avoid  the  applica- 
tion of  ligature. 

Among  the  (a)  provisory  substitutes  we  have  chiefly  com- 
pression and  first  of  all  its  simplest  and  most  important 
form,  viz., 

i.  Digital  compression.      This  is  used, 

a.  Either  directly  in  the  wound,  by  closing  the  chan- 
nels of  shot  or  puncture-wounds  with  the  finger,  as  we  have 
seen  already  (arterial  punctures),  or  we  press  several  fing- 
ers of  one  hand  upon  the  bleeding  spot  in  the  pharynx,  on 
the  tonsils  (after  tonsillotomy)  or  on  the  hard  gum  upon 
the  place  of  exit  of  the  arteria  palatina  desc.  (in  uranoplas- 
ty). In  default  of  a  resisting  base,  as  for  instance,  in 
bleeding  tonsils,  the  palm  of  one  hand  must  be  laid  under 
the  corner  of  the  jaw  to  produce  a  counter-pressure.  In 
cases  of  bleeding  of  the  arteria  palatina  desc.  it  has  been 
proposed  to  drive  in  small  wooden  plugs. 

b.  Or  we  may  compress  the  surroundings  of  the  wound,  al- 
ready existing  or  about  to  be  made,  in  operations  on  hare- 
lips, when  the  assistant  presses  together  with  his  thumb 
and  index  the  upper  lip  in  the  region  of  the  corner  of  the 
mouth,  so  that  on  cutting  the  lip-gap  the  child  loses  as 
little  blood  as  possible. 

c.  We  exert  a  compression  indirectly  upon  the  trunk  of 
the  supplying  artery.  This  should  be  the  first  thing  in 
all  haemorrhages,  where  we  cannot  reach  its  source  immedi- 
ately (continuous  digital  compression  of  the  supplying 
artery-trunk  has  also  proved  valuable  in  the  treatment  of 
aneurisms),  then  in  amputations,  as  adjunct  to  Esmarch's 
bandage,  before  and  after  its  completion,  or  where  the 
presence  of  suppurating  cavities  prevents  the  continuous 
bandaging  as  far  as  the  point  of  constriction.  Here  we 
raise  the  extremity,  compress  the  supplying  arterial  trunk 
and  wind  the  bandage  only  as  far  as  the  inflammatory 
infiltrated  region,  or  that  which  contains  the  suppurating 
cavities  and  then  we  add  constriction  above  that  region. 

It  is  very  important,  gentlemen,  that  you  use  every 
opportunity  of  making  yourselves  familiar  with  the  exact 
position  of  the  points  for  pressure  of  the  great  arterial 
trunks. 

You   compress   the   arteria   maxillaris  ext.   against   the 


SURGICAL   EMERGENCIES.  37 

margin  of  the  lower  jaw  near  the  front  edge  of  the  mas- 
seter  muscle.  To  compress  the  carotid  you  must  always 
stand  behind  the  patient,  lay  your  thumb  on  his  neck  and 
exert  a  pressure  with  the  three  middle  fingers  of  your  hand 
in  ,the  furrow  between  the  larynx  and  the  sterno-cleido 
mastoid  in  the  direction  of  the  spine  and  as  much  as 
possible  in  the  direction  of  the  central  line  of  the  spine; 
thereby  you  will  avoid  the  simultaneous  and  painful  com- 
pression of  the  vagus  nerve.  For  the  compression  of  the 
subclavian  the  patient  must  lie  horizontally  or  with  the 
upper  part  of  his  body  raised;  you  stand  at  his  head  and 
press  the  artery  towards  his  first  rib  with  your  thumb  in 
his  fossa  supraclavicularis.  There  is  another  fact  you  must 
remember  in  case  of  a  sudden  haemorrhage  from  the 
arteria  axillaris,  namely,  the  possibility  of  completely 
interrupting  the  radial  pulse,  in  pressing  the  arteria  sub- 
clavia  between  the  middle  part  of  the  clavicle  and  the  first 
rib,  by  pressing  the  shoulder  of  the  patient  heavily  down 
and  hindwardly.  In  order  to  interrupt  the  pulsation  of 
the  arteria  brachialis,  you  either  clasp  from  the  outerside 
of  the'  arm  the  biceps  lump  from  above  or  the  triceps  lump 
from* below,  so  that  your  thumb  is  on  the  outward  side  of 
the  upper  arm,  while  the  other  fingers  press  the  artery  in 
the  sulcus  bicipit.  intern,  in  the  direction  of  the  shaft  of 
the  humerus,  avoiding  the  n.  median  nerve. 

The  point  of  compression  for  the  arteria  radialis  is,  by 
reason  of  its  superficial  position,  easily  found  by  any  one, 
"there  where  the  pulse  is  felt."  Much  more  difficult,  in 
spite  of  its  superficial  position,  is  the  precise  compression 
of  the  arteria  femoralis  under  Poupart's  ligament.  The 
spot  is  easily  found,  if  we  remember  that  the  artey  crosses, 
in  its  course,  the  ligament  exactly  in  the  middle.  We  need 
therefore  only  to  divide  the  distance  between  the  spina 
ant.  sup.  of  the  ilium,  and  the  symphysis  into  two  equal 
parts,  mark  the  centre  point  with  some  coloring  matter,  in 
order  to  be  able  to  find  the  artery  at  any  moment  without 
failure,  and  to  press  it  tightly  against  the  horizontal  ramus 
of  the  os  pubis.  Never  omit  to  mark  with  ink  or  colored 
pencil  the  position  of  the  femoralis,  when  in  impending 
haemorrhages  its  rapid  compression  falls  to  other  hands 
than  yours.  Haemorrhages  from  the  art.  femoralis,  even  of 
very  short  duration,  have  frequently  resulted  in  death.  We 
have  already  spoken  of  the  compression  of  the  aorta  from 
the  direction  of  the  rectum. 


38  SURGICAL  EMERGENCIES. 

2.  The  compression  can  be  made  with  suitable  instruments. 
Either  with  such  which,  as  the  finger,  touch  the  vessel 
alone  ;  these  are  the  compressors :  or,  the  vessel  is  com- 
pressed either  together  with  its  surroundings  or  by  them. 
This  idea  suggested  the  original  construction  of  tourni- 
quets. Among  the  compressors  the  simplest  and  directest 
imitation  of  the  pressing  finger  is  Ehrlich's  crutch  for  the 
subclavian,  which  may  be  improvised  out  of  any  strong 
key,  the  crest  of  which  is  wrapped  in  cotton. 

A  compressor  for  the  aorta  we  have  already  mentioned  in 
in  connection  with  the  elastic  bandage.  A  similar  one, 
named  after  Dupuytren-Colombat,  consists  of  a  cushion  for 
the  lumbar-vertebral  column,  of  a  semi-circular  metal  arch, 
which,  at  correspondent  distance,  bends  over  the  abdomen, 
and  of  an  adjustable  pelotte,  which  is  to  press  the  epigas- 
tric aorta  perpendicularly  towards  the  vertebral  column. 
On  the  same  pattern  is  constructed  the  aortic  compressor 
which  Tiemann  manufactured  for  the  American  army.* 
Similar  to  these  is  Bulley's  double-compressor,  which,  in 
popliteal  aneurisms,  is  to  compress  the  arteria  femoralis  in 
its  extent  from  Poupart's  ligament  to  the  middle  of  the 
upper  thigh,  alternately  on  two  spots. 

Among  the  tourniquets,  the  twist-tourniquet  is  the  oldest 
and  the  most  primitive.  Hans  von  Gerstorff  (Schylhaus) 
describes  it  in  his  Text-Book  of  Surgery  in  the  beginning 
of  the  sixteenth  century.  Others  maintain  that  Morel  used 
the  twist-instrument  first  during  the  siege  of  Besancon  (1674). 
At  any  rate,  the  twist-tourniquet  deserves,  on  account  of 
its  simplicity,  and  because  it  may  be  easiest  improvised,  the 
preference  over  all  others,  provided  the  pressure  is  accu- 
rately calculated.  This  is  particularly  applicable  to  military 
surgery,  which  must  not  be  deprived  of  the  tourniquet. 
The  introduction  of  Esmarch's  rubber  bandage  for  tempo- 
rary haemostasis  on  the  battle-field  is  generally  impractica- 
ble, because  rubber  soon  loses  its  utility,  as  observed  above, 
under  the  influence  of  changing  temperature.  The  propo- 
sition of  Bardeleben  is,  therefore,  more  practical,  viz.,  to  use 
for  Esmarch's  bandage  on  the  battle-field,  instead  of  rubber 
bands,  firmly  woven  linen  bandages;  to  raise,  before  putting 
them  on,  the  respective  part  of  the  body,  and  to  moisten 

*  A  report  on  amputations  at  the  hip-joint  in  military  surgery.  Circu- 
lar 7,  p.  81,  of  the  War  Department.  Surgeon-General's  Office,  U,  S.  A. 
1867. 


SURGICAL   EMERGENCIES.  39 

them  slowly  after  the  bandaging  from  the  periphery  to- 
wards the  center.  Instead  of  the  rubber  tube  and  the 
constriction  bandage,  a  twist-tourniquet  without  pelotte  is 
fastened  on  with  like  result  (Kohler,  /.  c.) 

Approaching  the  twist-tourniquet  is  that  proposed  by 
Assalini  (1812),  the  buckle-tourmquzt',  more  complicated 
and  easier  disarranged  is  the  jrn?w-tourniquet  of  J.  L.  Petit, 
which  has  enjoyed,  from  the  beginning  of  the  eighteenth 
century,  great  popularity,  and  of  which  many  modifications 
exist. 

As  it  is  only  a  matter  of  historical  interest,  we  shall  be 
as  brief  as  possible  in  our  mention  of  the  permanent 
substitutes  for  ligature,  since  we  posess  in  catgut  and 
carbolized  silk,  in  carrying  out  the  antiseptic  method,  in- 
deed the  simplest  and  most  perfect  means  of  effectually 
closing  arteries. 

The  oldest,  so  to  speak,  the  prototype  of  our  modern 
method  of  ligation,  is  the  mass-ligature,  just  as  Pare  applied 
it.  Roser  lately  recommended  it,  justly,  as  a  method  of 
circumsuture  for  those  cases  where  we  are  not  able  to  look 
for  or  isolate  the  bleeding  vessels. 

In  a  wider  sense  the  percutaneous  circumsuture  belongs 
here,  which  was  proposed  by  Middeldorp  for  haemorrhages 
from  the  palmar  arch,  where  compressing  threads  are  con- 
ducted through  the  entire  thickness  of  the  fleshy  parts  of 
the  hand,  between  the  bones. 

The  second  substitute  for  simple  thread-ligature,  the 
so-called  temporary  ligature,  has  an  interesting  history  of 
development,  as  it  is  a  sequence  to  the  numerous  experi- 
ments with  animals,  made  by  Jones,  Travers,  Scarpa,  B.  U. 
Walther  et  al,  in  regard  to  the  mechanism  of  complete 
arterial  hasmostasis.  The  different  methods  of  temporary 
arterial  ligature  and  temporary  arterial  closure  were  founded 
on  the  observation  that  an  arterial  tube,  which  has  been 
ligated,  bruised,  or  even  only  compressed  for  a  few  days, 
becomes  permanently  impervious  to  the  flow  of  blood;  and 
suggested  by  the  consideration  of  the  former  disadvantages 
and  dangers  of  the  simple  thread-ligature,  which  was  only 
dissolved  by  the  complete  severance  of  the  artery. 

In  order  to  be  able  to  remove  the  thread  at  the  desired 
time,  after  a  temporary  arterial  ligature,  little  pieces  of 
cork  were  inserted  between  the  thread  and  the  artery 
(Cline,  Forster),  or  little  wooden  plates  (Desault),  or  little 
rolls  of  sticking-plaster  (Rous),  or  linen  (Scarpa's  cylinder- 


40  SURGICAL  EMERGENCIES. 

ligature),  or  peculiar  ligature  knots  were  made,  which  were 
easily  loosened  by  pulling  the  ends  of  the  thread,  ("  reef- 
knot"  of  Churchill,  Mattel's  loop  a  la  Ricord,  Ogston's 
simple  knot  with  bow).  Finally,  threads  and  loops  of  metal 
wire  were  used,  which  were  drawn  through  particular  little 
arterial  tubes,  or  ligature-tubes,  stretched  tightly,  and  sub- 
sequently cut  through  and  pulled  out  of  the  wound.  (Del- 
pech,  Walther,  V.  Bruns,  Peters,  Van  Gieson,  N.  P.  Smith, 
Baltimore,  Prichard.)     The  last  named  used  horsehair. 

For  arterial  closure  we  find  particular  compressors  used, 
of  which,  to  the  present  day,  there  exist  about  two  dozen 
different  forms.  (Literature,  see  P.  Bruns:  "  Temporary 
Ligature  of  Arteries,"  /.  e.)  According  to  the  principles, 
which  came  into  consideration  in  applying  the  above  men- 
tioned compressors,  special  names  have  been  chosen  for  the 
different  modifications  of  arterial  closure,  (Vanzetti's  Unci- 
pressure,  Verneuil's  Forcipressure,  Pean's  "  Pincement  des 
Vaisseaux,"  etc.)  The  next  space  in  this  arrangement  is 
best  occupied  by  the  torsion  of  arterial  stumps  (Am ussat's 
torsio  arteriarum),  which  is  always  useful  for  small  vessels, 
and  has  even  been  found  by  several  surgeons  reliable  for 
large  arterial  trunks  (Bryant).  And  finally  the  acupressure 
of  Simpson,  and  the  acutorsion  of  Billroth,  which  were  sent 
forth  with  so  much  eclat,  and  are  widely  used.  In  the 
former  the  injured  vessel  is  pressed  with  the  aid  of  a  long 
needle,  which  is  drawn  through  behind  it,  either  against  the 
skin  surface,  or  against  the  fleshy  part,  or  against  the  bone, 
according  to  the  position  of  the  vessel  in  the  amputation 
wound. 

Acufilopressure  is  described  (Dix,  Keith)  as  a  procedure 
where  the  vascular  tube  is  pressed  with  the  aid  of  a  wire 
loop  entwined  in  the  shape  of  an  8,  toward  a  needle, 
inserted  into  the  fleshy  parts.  In  acutorsion  the  vascular 
tube  is  also  twisted,  by  means  of  long  needles,  around  its 
own  longitudinal  axis,  either  around  one  or  two  right 
angles,  as  the  case  may  be,  and  closed  in  this  manner. 


SURGICAL  EMERGENCIES.  41 


LECTURE  V. 

Hemorrhages  from  veins. —  Their  frequency,  cause,  and  occur- 
rence.— Phlebitis. — Periphlebitis. — Phleboplastic  hemorrhages 
of  Stromeyer.  —  Spontaneous  hemostasis.  —  Vein-ligature.  — 
Substitutes  for  vein-ligature.  —  Tamponing  in  sequestral  cavi- 
ties, in  hemorrhage*  from  the  rectuni,  the  vagina,  the  uterus. — 
Treatment  of  hemorrhages  from  the  nose. — Bellocq's  tube. — 
Bandage-wrapping.  —  Capillary  hemorrhages.  —  Search  for 
bleeding  point. —  Tamponing  with  bandage-wrapping . — Styptic 
tamp07is. — Heat  and  cold. — Hot  douches  as  safe  hemostatic 
means. —  Glow  -  heat. — Catdery  iron. — Galvano  -  cauterizer. — 
Paquelin. — Chemical  hemostatic  means. 

Haemorrhages  from  venous  vessels  are  more  frequent 
than  those  from  arteries,  partly  because  the  former  are 
more  numerous  and  nearer  the  surface,  partly  because  the 
thin  venous  wall  is  easily  torn  and  crushed  by  only  mode- 
rate collision  with  blunt  objects,  to  which  the  surface  of 
our  body  is  exposed  in  ordinary  life,  while  the  elastic 
arterial  wall  yields  to  the  force  exerted  upon  it. 

Besides,  in  fresh  wounds,  venous  haemorrhages  occur 
particularly  easily  where  the  development  of  the  venous 
wall  is  faulty,  as  in  tumors,  or  where  morbid  changes  have 
taken  place  in  the  venous  wall,  principally  in  varicose  de- 
generations. Haemorrhages  from  bursting  varices,  for  in- 
stance, at  the  upper  thigh,  in  the  trigonum  urethras,  in 
women  in  the  labia  majora,  often  assume  a  dangerous 
character  and  may  cause  high  degrees  of  anaemia. 

The  venous  haemorrhages,  observed  in  amputation 
stumps,  have  likewise  particularly  attracted  the  attention 
of  surgeons.  The  latest  pathologico-anatomical  researches 
in  regard  to  the  connection  of  blood-poisoning  and  suppura- 
tion fever  with  the  so-called  inflammation  of  the  veins  and 
their  surroundings,  (Cruveilhier)  had  given  rise  in  the  minds 
of  investigators  to  a  fear  against  direct  ligature  of  injured 
veins  They  observed  the  venous  wall,  and  not  without 
reason,  to  be  particularly  susceptible  to  conveyance  of  in- 
fectious processes,  and  found  in  the  ligature-loop  the  irn- 


42  SURGICAL   EMERGENCIES. 

mediate  cause  of   the  development  of  phlebitis  and  peri- 
phlebitis. 

The  spontaneous  haemostasis  from  veins  of  small  calibre 
is  caused  by  the  tumefaction  of  the  surrounding  tissues, 
which  occurs  soon  after  the  injury,  and  arises  from  the 
clogging  up  of  the  tissue  juices.  In  large  vein  trunks  the 
haemorrhage  is  prevented  by  the  closing  of  the  valves,  if 
they  are  sufficient  for  the  purpose.  Nevertheless,  a  con- 
tinuous bleeding  may  be  maintained,  if,  underneath  the 
valve-lock,  a  collateral  branch  continues  to  empty  its  blood 
into  the  venous  stump.  An  insufficiency  of  the  venous 
valves,  however,  occurs,  either  in  a  high  increase  of  pressure, 
in  the  vein  region,  which  is  centrally  situated.  Thus  in  un- 
compensated heart  defects,  or  in  a  pressure  on  the  vena 
cava,  either  by  tumefactions  or  by  fluid  accumulations 
within  the  abdominal  cavity.  This  is  especially  the  case  in 
amputation  of  the  lower  extremities;  or  the  valves  are 
changed  by  the  processes  of  decomposition  which  take 
place  within  the  veins,  at  times  even  partly  destroyed,  and 
in  this  manner,  the  thrombus  which  obstructs  the  ve- 
nous lumen  likewise  becomes  subject  to  disintegration; 
haemorrhages  occur  which  have  been  designated  by  Stro- 
meyer  as  phlebostatic,  and  have  been  explained  by  embolia 
or  thrombosis  of  venous  branches  of  the  higher  order.  If 
we  wish  to  understand  what  Stromeyer  may  have  meant  by 
this  mode  of  explanation,  we  must  recall  to  our  mind  that 
the  simple  closure  of  individual  veins,  even  of  the  larger 
vein-trunks  at  any  particular  point  in  the  venous  region, 
on  account  of  the  numerous  collateral  branches,  does  as  yet 
not  produce  any  disturbance  of  circulation  in  the  venous 
system  of  an  extremity.*  But  that  the  obstruction  of  a 
larger  part  of  a  main  trunk  by  a  thrombus,  which  extends 
in  its  retrogression  into  the  collateral  branches,  very  soon 
causes  disturbances  of  the  venous  blood  circulation,  the  vis- 
ible sign  of  which  appears  in  an  engorgement  oedema.  The 
latter  cannot  be  caused  by  a  ligation  of  even  several  venous 
trunks  in  an  extremity.  The  infectious  periphlebitis,  in 
vein-injuries  or  vein-ligations  without  antiseptic  cautions, 
will,  however,  easily  lead  to  extensive  continuous  thrombosis 
within  the  venous  system  of,  e.g.,  a  leg  (phlegmasia  alba 
dolens). 

*  Sotnitschewsky,  Ueber  Stauungsadem.      Virchow's  Archiv  f.  path, 
Anat.  1879.    Bd.  77. 


SURGICAL   EMERGENCIES.  43 

From  what  we  have  seen  hitherto,  it  certainly  follows  that 
infectious  matter  exerts  its  deleterious  influence  particularly 
easily  within  the  course  of  vein-trunks,  upon  the  entire  or- 
ganism, but  that  it  is  transported  directly  through  the 
thrombus  and  blood-fluid,  or  through  the  net  of  lymph 
vessels  surrounding  the  veins.  Where  we  are,  therefore, 
able  to  prevent  the  processes  of  disintegration  in  wounds, 
intentional  or  unintentional,  there  the  direct  double  ligature 
of  veins  assumes  its  claim  as  the  most  reliable  means  of 
haemostasis.  Only  that  the  searching  for  and  ligating  of 
all  side-branches  is  necessary  in  veins  to  a  much  higher 
degree  yet  than  was  required  in  the  treatment  of  arterial 
punctures.* 

Nevertheless,  there  ar£  cases  where  we  have  to  forego 
direct  ligation  in  venous  haemorrhages,  be  it,  that  the  vascu- 
lar tube  is  difficult  to  seize  in  its  surroundings,  as,  for  in- 
stance, in  bones,  or  that  the  haemorrhage  issues  from  places 
which  are  not  directly  accessible  to  the  eye  and  the  finger. 
Here  we  may  endeavor  to  subdue  the  haemorrhage  by  com- 
pression of  the  vein  with  the  immediate  or  remote  surround- 
ings, and  only  in  the  rarest  cases  by  ligation  of  the  supply- 
ing arterial  main  trunk.  (Ligation  of  the  arteria  femoralis. 
B.  von  Langenbeck.) 

We  have  therefore  to  consider  more  extensively  the  tam- 
pon, with  or  without  bandaging,  as  a  remedy  for  haemor- 
rhages from  veins. 

Sequestral  cavities  in  bones  wnich  nave  been  chiseled 
open  we  best  fill  with  antiseptic  dressing  material  (Volk- 
man's  gauze,  or  after  lining  of  the  bone-cavity  with  car- 
bolized  gauze  or  preventive  taffeta  filling  with  antisep- 
tically  prepared  jute). 

For  many  cases,  particularly  where  a  simultaneous  strong 
influence  of  wound- secretion  or  other  fluids  (from  cysts  or 
body-cavities)  is  to  be  expected,  compression  is  better 
made  with  antiseptic  sponges. 

The  tampon  is  also  used  in  venous  haemorrhages  from  the 
recta wi,  the  vagina,  the  uterus  (in  placenta  praevia  and  uter- 
ine tumors).  After  removal  of  the  blood,  as  far  as  such  is 
possible,  we  must  use  for  the  tampon  numerous  balls  of  anti* 
septic  material  wrapped  tightly  with  antiseptic  threads,  of 
which  several  ends  must  hang  loose  to  enable  us  to  remove 

*  Rose,  Ueber  Stichwunden  der  Oberschenkelgefusse  urvd  ihre  sicher 
ste  Behandlung.     Sammlung  klinischer  Vortrage.  Nr.  02.. 


44  SURGICAL   EMERGENCIES. 

the  balls  by  their  aid.  For  bleeding  from  the  rectum,  the 
balls  are  pressed  in,  within  a  glove-shaped  piece  of  gauze 
linen  inserted  in  the  rectum.  The  balls  may  be  inserted 
directly  into  the  vagina  but  always  through  a  speculum  to 
protect  the  mucous  membrane  of  the  vaginal  entrance 
against  friction.  Perhaps  it  is  preferable  to  proceed  here 
also,  especially  if  no  speculum  is  at  hand,  exactly  as  in  tam- 
poning the  rectum.  If  compression  of  the  urethra  should 
hereby  occur,  the  catheter  must  be  used  for  the  removal  of 
the  urine.  As  a  substitute  for  the  method  just  mentioned, 
we  may  also  use  thin  rubber  balls,  which  are  inflated  with- 
in the  respective  channels  with  air  or  fluids  (kolpeurynter). 
For  haemorrhages  from  the  rectum  we  must  not  forget  digi- 
tal compression,  particularly  when  in  narcosis  we  are  able 
to  insert  several  fingers  or  the  whole  hand  after  previous 
dilatation  of  the  sphincter  ani.  For  this  purpose  we  insert 
our  two  indices  hook-shaped  into  the  rectum  and  draw  by 
jerks  the  sphincter  apart  in  the  sagittal  and  frontal  dia- 
meter. Profuse  haemorrhages  from  the  atonic  uterus  after 
recent  labor  have  also  been  successfully  stopped  by  direct 
compression  of  the  uterus  in  the  direction  from  the  rectum 
and  by  counter-pressure  from  the  hypogastrium  by  the 
other  hand.  It  scarcely  needs  mention  that  all  these  means 
only  counteract  haemorrhages  as  such,  and  not  their  direct 
cause,  and  that  in  case  of  their  repetition  their  cause  itse.Ji 
must  be  attacked. 

The  treatment  of  nose-bleedings  remains  to  be  considered. 

If  these  issue  from  the  outward  part  of  the  nose,  within 
the  region  of  the  cartilaginous  integument,  they  are  easily 
stopped  by  outside  compression,  by  pressing  the  nostrils 
against  the  septum.  If  the  bleeding  part  lies  deeper  inward 
between  or  upon  the  conchae  or  in  the  vicinity  of  the 
choanae  the  rinsing  of  the  nostrils  with  a  hot  solution  of 
chloride  of  sodium  (J  per  cent.)  may  be  sufficient.  In  pro- 
fuse haemorrhages  little  can  be  done  with  this.  Here  com- 
pression alone  is  of  avail,  but  not  from  the  outside,  for  while 
thereby  the  flow  of  blood  from  the  nostrils  may  be  pre- 
vented^ it  makes  its  way  through  the  choanae  into  the 
pharynx.  We  first  insert  a  catheter  or  tube,  invented  by 
Bellocq,  backward  into  the  nasal  cavities,  so  that  the  mouth 
of  the  catheter  or  the  perforated  ball  at  the  top  of  Bellocq's 
spring,  gliding  down  in  the  naso-pharyngeal  cavity  along 
the  posterior  wall  of  the  soft  palate,  becomes  visible  in  the 
posterior  part  of   the  oral  cavity.      The  loose   ends   of   a 


SURGICAL  EMERGENCIES.  45 

thread  are  fastened  to  the  top  of  the  catheter  or  to  the  per* 
forated  metal  ball  of  Bellocq's  instrument  just  described, 
while  the  tampon  which  is  to  be  conveyed  upward  into  the 
choanse,  is  to  be  crossed  by  the  middle  of  this  thread  in  the 
same  manner  as  a  bale  of  cotton  is  tied  with  ropes.  If  we 
now  pull  the  catheter  or  Bellocq's  tube  out  of  the  nose,  we 
drag  along  the  tied  up  ends  of  the  thread,  which  is  pulled 
out  of  the  nasal  cavity,  until  the  tampon,  which  is  tied  to 
the  centre  of  the  thread,  has  passed  the  soft  palate,  reached 
the  choanse  and  is  pressed  within.  But  the  tampon  must 
have  a  third  thread,  a  tail,  as  it  were,  which  hangs  out  of 
the  mouth  and  by  which  we  may  at  any  time  pull  the  tam- 
pon back  again  out  of  the  naso-pharyngeal  cavity.  The 
tampon,  however,  is  fastened  in  the  choanse  by  tying  the 
ends  of'the  thread  which  hang  from  the  nostril  over  a 
cotton  pledget  inserted  into  the  latter  or  over  a  piece  of 
thick  rubber  tube,  resting  against  the  nostril.  If  neither  a 
catheter  nor  one  of  Bellocq's  instruments  is  at  hand,  a 
pliable,  smooth  stick  of  wood  may  be  used  for  the  insertion 
of  the  threads.     (Thomas.*) 

For  exceptional  cases,  where  no  instrument  at  all  is  at 
hand  to  guide  the  thread  through  the  nasal  into  the 
pharyngeal  cavity,  by  means  of  which  the  tampon  is  to  be 
pulled  up  into  the  choanse,  we  may  try  in  case  the  nasal 
cavity  is  not  entirely  stopped  up  or  the  patient  too  weak, 
the  following  procedure  :  we  fasten  the  loop  of  a  double 
thread  in  a  leaden  ball  of  about  the  size  of  a  cherry-pit,  by 
opening  it  first  and  then  pressing  it  together  again.  The 
head  of  the  patient  is  pulled  far  back  and  the  ball  is 
dropped  into  one  of  the  nostrils,  while  the  patient  is  made 
to  snuffle  as  hard  as  possible.  By  its  own  weight  and  the 
aspiratory  current  of  air  the  ball  penetrates  into  the  naso- 
pharyngeal space  and  is  forced  by  the  patient's  suffocative 
movements  into  the  anterior  parts  of  the  mouth.  Now  we 
may  fasten  the  tampon  to  the  loop  of  the  double  thread 
just  as  above.  ^ 

The  wrapping  with  bandages,  which  is  of  course  required 
for  the  tamponing  of  venous  hsemorrhages  on  the  surface  of 
the  body,  may  be  applied  also  more  independently.  The 
methodic  involution  of  extremities,  named  after  Theden, 
where  the  part  is  bandaged  from  the  periphery  toward  the 
centre,  has  been  recommended,  in  combination  with  plac- 

*  Thomas,  Traits  dcs  operations   d'urgences,   Paris  1875. 


46  SURGICAL  EMERGENCIES. 

fng  the  arm  on  a  splint,  after  puncture  wounds  of  the 
brachialis  in  venesection  of  the  elbow-joint.  The  bandage 
is  also  excellent  in  haemorrhages  from  cedematous  or  in- 
flammatory infiltrated  parts,  as  well  as  in  haemorrhages 
from  varices. 

Those  haemorrhages  where  it.  is  difficult  to  discover  the 
bleeding-point  have  always  been  called  capillary,  or  surface 
haemorrhages.  And  yet  the  discovery  will  often  be  possible 
by  great  care;  and  then  the  application  of  a  ligature  will  fur- 
nish a  permanent  haemostasis. 

Capillary  surface  haemorrhages  occur,  first,  after  opera- 
tions, e.g.,  after  dissolution  of  adhesions  within  the  abdom- 
inal cavity  in  ovariotomy.  Also  after  extraction  of  teeth, 
particularly  of  the  so-called  "  bleeders"  or  "  hemophiles." 
Then  after  leech-bites  and  from  cut-wounds  of  the  skin,  as 
well  as  after  cut-wounds  in  plastic  operations.  Likewise 
considerable  haemorrhages  from  granulation  cells  may  issue 
at  a  pressure  upon  the  large  venous  trunks  of  the  respira- 
tory regions,  e.g.,  by  tumefactions  or  by  a  rise  of  venous 
tension  in  uncompensated  defects  of  the  heart;  consequently 
under  very  similar  conditions  to  those  under  which  haemor- 
rhages from  veins  occur.  Finally,  so-called  capillary  haem- 
orrhages occur  from  ulcerated  tumors,  e.g.,  haemorrhoids 
and  disintegrating  cancer  of  breast  or  uterus. 

We  have  already  remarked  that  we  must  strive  to  discover 
the  bleeding-points,  even  in  haemorrhages  of  the  smallest 
vessels,  and  to  seize  them  after  isolation.  Where  the  most 
reliable  means  fail  we  have  to  adopt  substitutes,  among 
which  the  mechanic,  the  thermically,  and  chemically  acting 
ones  are  to  be  distinguished. 

Here,  also,  as  in  venous  haemorrhages,  the  direct  tampon, 
supported  by  centripetal  ligation,  claims  its  place.  But  the 
direct  compression  of  the  bleeding  parts  with  the  finger  or 
a  ball  of  antiseptic  dressing  material  appears  the  simplest, 
most  suitable  precursory  haemostatic  during  an  operation. 

In  similar  manner  we  stop  bleeding  in  plastic  operations, 
and  from  obstinately  bleeding  leech-bites,  by  suture,  acting 
in  the  mode  of  compression.  Particularly  in  plastic  oper- 
ations we  would  twist  only  the  somewhat  larger  bleeding 
trunks. 

Further,  the  tampon  may  be  effected  with  materials  which, 
aside  from  compression,  are  also  to  act  on  account  of  their 
being  saturated  with  substances  which  act  encrustingly  both 
on  the  blood  and  on  the  vessels.     As  our  object  is   here 


SURGICAL  EMERGENCIES.  47 

haemostasis  and  not  disintegration  of  the  vessels,  we  must 
always  observe  the  rule,  that  the  styptic  balls  must  be  made 
very  small  and  pressed  directly  upon  the  bleeding-point, 
after  it  has  been  thoroughly  cleansed  of  all  coagula;  other- 
wise we  cause  encrustations  of  the  surroundings  of  the 
bleeding  part,  the  consequences  of  which  cannot  be  calcu- 
lated, and  the  haemorrhage  may  continue  after  all,  as  many 
examples  have  shown. 

As  styptic  means,  we  use  most  commonly  fuming  nitric 
acid,  then  crystallized  carbolic  acid  and  chloride  of  iron. 
The  cauterization  with  carbolic  acid  acts  at  the  same  time 
anaesthetically,  so  that,  for  painful  cauterization,  a  previous 
application  of  carbolic  acid  has  been  recommended.  Liq. 
ferri  sesqui-chlor.  has  been  found  specially  effective  in  hem- 
orrhages from  the  dental  alveoli  after  tooth-extraction, 
because  the  crust  which  it  produces  remains.  It  is  to  be 
regretted  that  it  is  almost  not  at  all  antiseptic,  so  that  fre- 
quent rinsing  becomes  necessary  to  avoid  its  very  offensive 
decomposition. 

To  this  day  we  are  not  clear  as  to  the  application  of 
thermic  means,  particularly  as  to  the  action  of  cold.  Physi- 
ological experience  teaches  that  cold  retards  the  coagulation 
of  the  blood.  Haemostatically  it  can  therefore  not  act  by 
way  of  coagulation,  but  only  by  stimulating  vascular  con- 
traction there,  where  we  have  a  sufficient  circular  muscular 
structure  of  vessels.  The  action  of  fluids,  heated  far  above 
the  temperature  of  the  body,  is  similar  (water,  solutions  of 
common  salt,  chloride  of  zinc,  carbolic  acid),  only  that  to 
the  stimulation  of  vascular  contraction  is  added  the  other 
action  of  heat,  long  known  to  physiologists,  which  consists 
in  enhancing  coagulation.  The  application  of  the  hot 
douche  will  therefore  stand  by  us  also  where  vascular  con- 
traction is  not  obtained.  It  is  strange  enough  that  it  was 
the  accoucheurs  who  first  called  attention  to  the  reliable  ap- 
plication of  hot  solutions  (hot  douche  in  uterine  haemor- 
rhages, particularly  after  miscarriages). 

Most  text-books  on  surgery  insist  with  traditional  unction 
on  recommending  the  dripping  of  icy-cold  solutions  for 
stopping  capillary  haemorrhages. 

I  consider  it  therefore  my  duty,  gentlemen,  to  call  your 
attention  particularly  to  it,  that  in  surface  haemorrhages, 
especially  in  the  pharyngeal  and  nasal  cavities,  but  also  from 
other  bony  parts  of  the  body,  as  well  as  from  bone  cavities 
and  osteotomic  surfaces,  after  sequestrotomy,  after  ampu- 


48  SURGICAL   EMERGENCIES. 

tations  and  resections,  you  will  reach  your  object  of  stay- 
ing the  flow  of  blood  much  more  surely  by  using  for  drip- 
ping and  douching,  hot  indifferent  solutions  containing  -£ 
per  cent  of  chloride  of  sodium,  or  like  antiseptic  solu- 
tions. 

Haemostasis  is  also  obtained  by  using  the  higher  and  the 
highest  degree  of  heat  for  cauterizing.  The  cautery-iron, 
in  its  different  shapes  (cone,  ball,  coin-shapes),  the  porcelain 
cauterizer  of  the  galvano-caustic  apparatus,  and  the  differ- 
ently-shaped platina-cupolae  of  Paquelin's  thermo-cauterizer, 
cauterize,  as  do  styptica,  both  blood  and  vessels,  and  must 
therefore,  like  the  styptica,  only  be  applied  to  the  bleeding- 
point.  As  only  certain  degrees  of  heat  enhance  coagula- 
tion, degrees  which  do  not  exceed  the  temperature  of  the 
body  too  much,  at  any  rate,  lie  below  the  point  at  which 
albumen  coagulates,  so  escharotization  is  only  produced  by 
red-glow  heat.  White-glow  heat  chars  both  vessels  and 
blood.     White-hot  iron  does  no  longer  produce  haemostasis. 

The  cautery-iron  is  particularly  effective  in  haemorrhages 
from  disintegrated  vessels,  because  it  simultaneously  sub- 
dues, often  in  a  striking  manner,  by  stopping  the  hitherto 
florid  processes  of  disintegration,  and  stimulates  the  forma- 
tion of  healthy  young  tissue.  So  in  haemorrhages  from 
granulations,  affected  by  hospital  gangrene,  in  haemorrhages 
from  suppurating  cancers  of  the  mammary  gland,  the  uterus 
and  the  rectum. 

There  are  but  few  purely  chemical  means  which  are  reliable 
in  their  action  for  haemostasis.  We  mention  first  acidum 
tannicum,  which  is  strewn  in  powder  upon  the  bleeding  sur- 
face, or  which  inform  of  tannin-glycerine  pencils, has  been 
recommended  particularly  for  introduction  into  the  uterus 
cavity.  Argentum  nitricum  as  a  haemostatic  remedy,  pos- 
sesses but  weak  power:  (compare,  however,  its  strong  power 
of  vascular  contraction  in  the  experiments  made  by  Rosen- 
stein*).  But  much  more  frequent  is  the  use  of  liquor  ferri 
sequichlor.  in  solutions  for  haemostatic  injections  into  the  rec- 
tum and  uterus.  Let  us,  finally,  mention  the  oil  of  turpen- 
tine, whose  haemostatic  action  has  been  frequently  proved. 
For  subcutaneous  injections  ergotine  has  been  used.  In  this 
case  the  extractum  secalis  cornuti  aquos.  has  been  diluted 


-  Rosenstein  Untersuchungen  iiber  die  ortliche  Einwirkungder  sogen- 
anten  Adstringentia  auf  die  Gefasse.  Verhandlungen  d.  physik.  med. 
Gesellschaft  in  Wurzburg.   1875.  Neue  Folge  IX.  Bd.  1 — 2.  Keft. 


SURGICAL  EMERGENCIES.  49 

with  equal  parts  of  aqua  distillata;  of  this  solution  a  quan- 
tity filling  Pravaz's  syringe  to  one  quarter  or  one  half,  has 
been  hypodermically  injected,  and  simultaneously  10  to  20 
drops  have  been  given  inwardly  every  half  hour. 

Besides  ergotine,  digitalis  and  plumbum  aceticum  deserve 
special  mention,  as  internal  remedies  for  haemorrhages,  the 
lungs,  for  instance. 


50  SURGICAL  EMERGENCIES. 


LECTURE  VI. 

Bleeding. — Its  value  as  a  hemostatic  remedy. — Other  indica- 
tions formerly  and  at  present. — Places  for  phlebotomy. — 
Phlebotomy. —  Topography  of  the  elbow. —  Technique  of  phle- 
botomy.— Phlebotomic  aneurisms. — Phebotomy  on  the  foot  and 
the  neck. — Arteriotomy  and  its  present  indications. — Capillary 
bleeding:     Its  real  value. — Scarification. — Cupping. — Leeches. 

Transfusion. — Historic  periods. — Defibrinated  atid  "intact'' 
blood. — Different  methods  of  transfusion. — Actions  of  the 
blood-discs,  of  the  serum  and  the  gaseous  contents  in  the  blood 
of  different  species  of  animals. — Significance  of  fibrin-fer- 
ment.— Central  arterial  blood  infusion. —  Venous  transfusion. 
— Ingress  of  air  into  veins.  — Result  of  experiments.  — Blood- 
injection  under  the  skin  and  into  the  abdominal  cavity. — Tech- 
nique of  transfusion. — Symptoms  in  transfusions. — Present 
Indications. —  Territories  of  ancemia. — A uto-transfusion. 

However  paradoxical  it  may  appear  to  introduce  bleed- 
ing as  a  means  of  haemostasis,  the  position  it  holds  as  such 
is  nevertheless  perfectly  clear.  The  decrease  of  blood 
pressure  and  the  diminution  of  arterial  tension  are  its 
haemostatic  factors.  They  may,  it  is  true,  be  obtained  only, 
as  we  have  seen,  by  incomparably  great  losses  of  blood, 
which  frequently  are  much  larger  than  the  quantity  to  be 
economized  by  haemostasis. 

In  former  times  venesection  was  resorted  to  much  more 
frequently,  as  bleeding  was  held  in  high  repute,  not  only 
as  a  haemostatic,  but  also  as  an  anaesthetic  and  antiphlo- 
gistic remedy. 

As  an  anaesthetic  means  we  find  venesection  resorted  to  as 
early  as  Galen,  at  the  time  of  Marcus  Aurelius,  130  after 
Christ,  and  until  chloroform  was  introduced  to  produce 
unconsciousness  and  facilitate  the  performance  of  difficult 
surgical  operations  (reduction  of  dislocation  of  the  femur, 
reduction  of  strangulated  ruptures,  etc.).  As  antiphlogistic 
means  venesection  came  into  use  through  the  doctrine  of 
erases.  And  here  we  find  it  chiefly  used  by  the  French 
school   of  Broussais,    and    then  with    alarming   frequency 


SURGICAL  EMERGENCIES.  5  I 

consistently  carried  on  in  all  typhous  diseases,  even  to 
anaemia  (Jugulade).  The  Vienna  school  first  succeeded 
(Van  Swieten,  Skoda)  in  resisting  this  senseless  waste  of 
blood. 

To-day  bleeding  is  pointed  out  as  a  remedy  in  some  few 
cases,  aside  from  those,  of  course,  where  the  removal  of 
blood  which  is  poisoned  or  incapable  of  performing  its 
functions  is  at  issue,  or  that  use  of  it  where  the  extracted 
blood  is  to  be  injected  into  a  second  person. 

Thus,  bleeding  has  been  recommended: 

a.  In  sanguineous  apoplexy  of  the  brain.  Here  its 
action  of  decreasing  the  pressure  of  the  blood  is  considered 
as  the  haemostatic  cause.     (See  above.) 

b.  Likewise  in  hyperaemia  of  the  lungs,  bleeding  has 
been  recommended  by  Stromeyer,  in  consonance  with  the 
advice  of  veteran  military  surgeons,  and, then  not  as  an 
antiphlogistic  means,  but  likewise  as  a  haemostatic  one 
(because  it  is  better  to  empty  the  blood  by  cupping  than  to 
let  it  flow  into  the  thorax.  Stromeyer.  Maxims  of  Military 
Surgery,  p.  444.)  But  here  as  well  the  result  of  bleeding 
will  only  then  come  about  when,  as  observed  above,  very 
large  quantities  of  blood  have  been  withdrawn.  Therefore 
it  is  preferable,  in  hyperaemia  of  the  lungs,  to  mitigate  the 
pain  and  distress  of  breathing  by  hypodermic  injections  of 
morphine,  and  to  attempt  an  immobilization  of  the  respec- 
tive parts  of  the  thorax  by  position  and  by  bandages.  I  at 
least  have  gained  by  the  latter  and  by  sleep,  as  the  result 
of  morphine,  more  than  by  unconsciousness,  resulting  from 
copious  bleeding,  and  I  have  seen  others  do  the  same. 
But  after  having  learned  from  the  results  of  antiseptic 
wound  treatment  that  the  dangers  in  opening  large  body- 
cavities  lie  elsewhere' than  in  the  mere  exposure  to  air,  it 
will  be  the  task  of  the  future  to  conceive  and  try  a  direct 
haemostasis  in  pulmonary  hemorrhages,  if  possible,  under 
protection  of  antiseptics,  after  the  affected  part  of  the 
thorax  has  been  laid  open. 

Finally,  bleeding  is  recommended 

c.  In  pneumonia  attended  by  cyanosis.  This  is  the  sur- 
vival of  the  old  method,  when  no  case  of  pneumonia 
escaped  bleeding.  Bleeding  in  pneumonia  is  recommend- 
able  with  very  robust,  powerful  persons,  before  the  acme 
of  the  disease,  whereby  and  by  the  momentary  insuffi- 
ciency of  the  right  ventricle,  blood  accumulations  arise  in 
the  venous   system  ;  but  it   should  never  be  employed  in 


$2  SURGICAL  EMERGENCIES. 

pneumonia  in  the  case  of  drinkers.  In  this  case  we  must 
resist  the  collapse  by  stimulants,  and  principally  by  copious 
alcoholic  doses. 

Formerly  they  used  to  divide  bleedings  into  three 
classes  :  large,  at  2  pounds  of  blood  (about  1  litre); 
medium  at  300-350  cam.,  and  small  at  200-250  c.c.m.  of 
blood.  And  bleeding  was  performed  on  different  venous 
trunks  of  the  body,  as,  for  instance,  at  the  jugular  vein  in 
the  middle  of  the  neck,  particularly  in  strangulation  and 
apoplexy  of  the  brain.  Danger  was,  apprehended  with  this 
method  on  account  of  the  possibility  of  the  penetration  of 
air  into  the  heart,  of  which  we  shall  speak  more  exhaus- 
tively in  the  subject-matter  of  Transfusion.  Also  on  the 
dorsum  pedis  and  the  vena  saphena  magna  of  the  upper 
thigh.  Now,  bleeding  is  performed  almost  exclusively  at 
the  elbow,  mostly  on  the  vena  mediana  basilica.  The 
trunk  of  the  vena  basilica  on  the  ulnar  side  of  the  arm, 
and  the  vena  cephalica  running  on  the  radial  side  of  the 
arm,  absorb  a  few  superficial  and  the  deep  venous  branches 
of  the  forearm  in  such  a  manner  that  the  latter  unite  to 
one  trunk,  and  this  one  in  its  turn  empties  its  blood  through 
a  diagonal  tube  or  through  a  forked  tube  partly  into  the 
vena  cephalica  and  partly  into  the  vena  basilica,  almost 
twice  its  own  size.  Consequently  the  ulnar  branch  of  the 
venous  fork,  the  vena  mediana  basilica,  is  the  stronger 
developed  and  the.  more  suitable  for  bleeding,  which  also 
appears  as  the  second  thicker  cord,  when  the  veins  of  the 
upper  arm  are  compressed  circularly  at  the  figure  M  of  the 
confluence  of  veins,  which  shines  through  in  a  bluish 
color.  The  vein  lies  upon  the  aponeurotic  continuation  of 
the  biceps  tendon,  which  radiates  towards  the  ulnar  side 
of  the  arm  and  is  separated  by  it  from  the  arteria 
brachialis,  which  lies  underneath,  crossing  its  direction. 
Above  the  vein  run  the  branches  of  the  nervus  cutaneus 
brachii  medius.  The  median  vein,  with  its  forked  branches, 
is  rarely  wanting  ;  only  at  times  the  vena  med.  cephalica 
and  the  med.  basilica  run  as  two  separate  branches.  In 
case  we  should  not  find  a  suitable  vein  in  the  elbow,  Lis- 
franc  advises  to  look  for  a  vena  salvatella  on  the  back  of 
the  hand  or  for  the  vena  cephalica,  where  it  runs  on 
the  upper  arm  between  the  deltoid  muscle  and  the  pec- 
toral. 

In  performing  our  phlebotomy  we  must  observe  the 
strictest  rules  of  cleanliness.     Formerly  periphlebitic,  and 


SURGICAL  EMERGENCIES.  53 

sven    pyaemic   processes  were    quite   often  observed   after 
this  apparently  innocent  operation. 

After  carefully  cleansing  the  field  of  operation  we  lay  on 
a  constricting  bandage  around  the  centre  of  the  upper  arm 
(phlebotomic  bandage,  formerly  of  red  color),  and  close  it 
with  a  loose  and  easily-opened  knot  (fascia  ante  venae- 
sectionem  comprimens).  The  operator  places  himself  so 
that  he  holds  the  hand  of  the  arm  on  which  the  bleeding 
is  to  be  performed  firmly  between  his  hip  and  his  right 
elbow.  The  thumb  of  his  left  hand  presses  upon  the  now 
copiously  filled  venous  trunk  below  that  part  of  the  elbow 
on  which  the  vein  is  to  be  opened.  This  is  best  done  with 
a  special  knife-blade,  protected  by  a  movable  covering. 
This  is  the  phlebotomic  lancet  which  has  become  so  re- 
markable in  the  history  of  many  a  physician,  and  which  in 
by-gone  times  was  often  the  sole  symbol  of  medical  knowl- 
edge and  surgical  ability.  According  to  the  form  of  the 
flat  two-edged  point  they  used  to  distinguish  a  more  thick- 
bellied  and  a  more  slender  shape  (the  phlebotomes  of 
barley-grain  and  oat-grain  shape).  With  the  safety-covers 
opened  upward  we  seize  the  lancet  close  to  the  point  with 
the  thumb  and  index  of  our  right  hand.  While  now  the 
fourth  finger  of  our  operating  hand  supports  itself  on  the 
fore  arm  of  the  patient,  and  the  third  and  second  fingers 
are  bent  in,  the  point  of  the  phlebotome  penetrates  into  the 
vein  in  an  oblique  direction  to  the  axis  of  the  vascular  tube. 
The  oblique  direction  is  chosen  to  obtain  a  wider  fissure  of 
the  vein.  On  diminishing  the  pressure  of  our  left  thumb 
the  accumulated  venous  blood  rushes  in  a  stream  into  the 
measuring  vessel  held  underneath.  (Phlebotomic  vessel.) 
If  the  bleeding  is  to  be  interrupted  we  need  only  to  renew 
the  pressure  of  our  left  thumb.  The  same  is  to  be  done  at 
the  end  of  the  operation,  when  the  phlebotomic  bandage 
is  quickly  unwound  and  a  further  loss  of  blood  is  perman- 
ently prevented  by  an  antiseptic  compression  bandage, 
which  is  to  take  the  place  of  the  finger  pressure.  In  time 
of  war  we  shall  often  be  compelled  to  content  ourselves 
with  an  antiseptic  ball  pressed  upon  the  phlebotomic 
wound.  At  any  rate,  it  is  advisable  to  wrap  subsequently 
the  entire  arm  in  a  bandage,  and  to  secure  its  quiet  position 
in  a  sling. 

An  injury  to  the  arteria  brachialis  is  prevented  by  using 
a  very  sharp  lancet,  and  by  inserting  its  point  very  slowly 
into  the  vein.     This  injury,  and  the  subsequent  formation 


54  SURGICAL  EMERGENCIES. 

of  a  so-called  phlebotomic  aneurism,  was  much  more  fre- 
quent after  the  substitution  of  the  usual  lancet  by  the 
spring-lancet,  an  instrument  so  unworthy  of  the  hand  of  a 
surgeon.  (Invention  of  Paasch,  a  Dutchman.)  An  injury 
to  the  artery  is  indicated  by  the  brightened  color  of  the 
blood-stream,  which  at  times  shows  pulsations.  But  a 
much  less  deceptive  sign  is  the  discontinuance  of  the  bleed- 
ing on  central  compression  of  the  trunk  of  the  arteria  bra- 
chialis  in  the  centre  of  the  upper  arm.  Sometimes,  when 
both  signs  are  absent,  a  swelling  is  to  be  noticed  in  the 
depth  of  the  phlebotomic  wound,  when  the  blood  from  the 
artery  does  not  flow  outward,  but  spreads  through  the  vas- 
cular layers  surrounding  the  artery. 

If  there  is  evidently  an  injury  of  the  artery,  do  not  waste 
time  in  attempting  compression,  but  lay  both  the  artery 
and  vein  open  and  ligate  both  doubly,  according  to  the 
rules  given  for  the  treatment  of  arterial  punctures.  It  is 
only  in  dubious  cases  that  you  can  content  yourselves  with 
a  compressing  ligature  of  the  entire  arm  with  subjoined 
longitudinal  pelotte  (thick  rubber  tube),  corresponding  to 
the  course  of  the  brachialis.  The  ligatures  mentioned  by 
former  surgeons  :  fascia  pro  venaesectione  in  cubito  and 
fascia  pro  aneurysmate  are  only  applicable,  together  with 
a  total  bandaging  of  the  arm. 

In  phlebotomy,  on  the  dorsum  pedis,  the  bandage  was 
applied  above  the  calf;  in  that  of  the  vena  jugularis  the 
bandage  had  to  be  supplied  by  compression  of  the  bulb  of 
the  vein  in  thetrigonum  of  the  sternocleido-mastoid  muscle. 

The  opening  of  an  artery  (arteriotomy)  to  withdraw 
blood,  without  intending  a  subsequent  transfusion,  is  prob- 
ably at  present  not  made  use  of.  It  was  recommended 
formerly  on  the  arteria  temporalis  in  affections  of  the  eye 
(Wardrop),  and  it  has  been  risked  to  puncture  the  artery 
like  a  vein,  through  the  skin,  which  ought  never  to  be  done, 
just  as  little  as  the  supplementary  application  of  a  simple 
compression-bandage,  even  if  we  were  to  choose  for  it  a 
ligature  knot  (fascia  nodosa).  If  an  artery  is  to  be  opened, 
be  it  for  the  purpose  of  making  a  blood-infusion  into  its 
peripheral  course,  as  Hueter  once  proposed,  or  with  the  in- 
tention of  injecting  blood  into  the  artery  toward  the  heart, 
or,  finally,  with  the  object  of  transfusing  the  arterial  stream 
directly  into  a  vein  of  another  individual,  the  arterial  vessel 
must  always  be  carefully  isolated  and  doubly  ligated  after 
the  transfusion  is  completed. 


SURGICAL   EMERGENCIES.  55 

Bleeding  of  smaller  vessels,  for  obtaining  blood  for 
transfusion,  has  been  proposed  but  in  isolated  instances 
(Gesellius),  while  the  so-called  capillary  bleeding  was  for- 
merly resorted  to  all  the  more  frequently  to  remove  a  sup- 
posititious local  hypersemia.  The  facility  of  performing 
the  pertinent  procedures,  together  with  the  importance 
which  the  vulgar  attributed  to  local  bleeding,  explains  how 
these,  even  more  than  venous  bleeding,  became  part  of  the 
practice  of  "  nurses  and  barbers,"  who  even  to-day  in  the 
eyes  of  the  public  represent  the  first  resource  for  surgical 
aid. 

Since  our  ideas  on  hyperemia  and  blood-distribution  in 
the  organism,  as  you  saw  in  our  first  lecture,  became  wholly 
different  from  our  former  ones,  the  indications  for  local 
bleeding  had  to  dwindle  down  to  a  minimum.  We  shall 
consider  its  application  justifiable  only  there,  or,  to  speak 
more  correctly,  we  shall  find  an  indication  for  local  influenc- 
ing of  the  conditions  of  circulation  there,  where,  either  by 
mechanical  or  inflammatory  processes,  the  local  arterial 
pressure  has  been  diminished,  or  where  a  direct  obstruc- 
tion to  venous  bleeding  exists.  In  both  cases  we  shall 
have  an  accumulation  of  blood  in  the  affected  parts,  and, 
as  its  consequence,  either  nutrition  disturbances  or  abnor- 
mal accumulations  of  fluids  within  the  tissues.  For  these 
cases  it  will  mostly  be  sufficient  to  bring  about  the  flow  of 
the  blood  by  opening  collateral  passages;  be  it  that  we 
produce  a  collateral  reflex  vascular  paralysis  by  means  of 
mechanical,  thermic,  or  chemical  irritation  (hsemospasis, 
humid  heat,  so-called  derivatives,  as  cantharides,  sinapisms, 
tincture  of  iodine).  It  will  be  but  rarely  required  to  draw 
the  blood  directly  to  the  outside,  which  is,  so  to  speak, 
temporarily  excluded  from  the  circulation,  and  menaces  by 
its  non-circulability  the  healthy  stability  of  the  tissues. 
And  even  then  we  shall  reach  our  end  more  precisely  and 
in  a  cleaner  manner  by  correct  incision  with  the  knife  than 
by  "capillary"  bleedings,  which  were  formerly  so  much  in 
favor,  of  which  we  shall  speak  more  exhaustively,  and  of 
which  we  mention  scarification,  the  cupping-glass,  and  the 
leech. 

Scarification,  formerly  praised  for  conjunctivitis-pannosa, 
hypertrophy  of  the  tonsils,  metritis  chronica,  and  acute 
glossitis,  consisted  in  puncturing  the  vessels  with  fine 
knives.  Lately  this  puncturing  has  again  been  resorted  to 
in  the  treatment  of  lupus;  but  there  it  is  claimed  that  it 


56  SURGICAL   EMERGENCIES. 

causes  the  shrinking  of  the  vessels,  not  by  blood  depletion, 
which  must  be  as  small  as  possible,  but  by  the  accompany- 
ing bisection  of  numerous  vessels,  which  spread  to  the  dif- 
ferent tumor-nodes,  and  by  this,  resulting  obliteration.  In 
acute  glossitis,  long  and  deep  knife-incisions,  parallel  with 
the  sagittal  lingual  axis,  which,  by  the  way,  are  but  little 
painful,  often  have  surprisingly  rapid  results,  particularly 
for  decreasing  the  swelling  of  the  organ.  In  hypertrophy 
of  the  tonsils,  the  best,  remedy,  both  in  the  inflammatory 
stage  and  after  its  abatement,  consists  in  excision  or  resec- 
tion. 

For  cupping,  an  apparatus  is  required  which  cuts  the 
main  vessels  and  draws  the  blood  into  an  attenuated  air- 
space. The  so-called  English  spring-lancet,  invented  by 
Lamzweerde  at  the  end  of  the  seventeenth  century,  answers 
the  first  purpose  ;  so  do  glass  or  metal,  about  hemi- 
spherical, concave  capsules  or  cups  (cupping-glasses, 
cucurbitse  ventouses).  These  are  heated  over  an  alcohol 
lamp  and  pressed,  after  wetting  the  edges,  to  the  skin.  The 
cooling  of  the  cup  causes  an  attenuation  of  the  air  within, 
allowing  the  blood  to  enter  the  vacuum  of  the  tightly- 
adhering  cup.  Opposed  to  these  so-called  wet  cups  are 
the  dry  cups  (ventouses  seches),  where  a  previous  incision 
of  the  skin  by  the  lancet  has  not  been  made.  Their  pur- 
pose consists  only  in  producing  local  hyperaemia  of  the 
skin.  With  this  purpose  we  see  them  yet  often  applied  to 
the  skin  of  the  thorax  in  inflammations  of  the  lungs  and 
the  pleura.  Such  hyperaemia  on  a  large  scale,  and  with  in- 
tended reaction  on  the  entire  body,  was  formerly  applied 
to  the  leg,  including  the  foot,  with  the  aid  of  the  giant-cup 
(ventouse  monstre)  of  the  so-called  Junod's  boot. 

For  haemospasia,  but  also  for  local  bleeding  in  the  vicin- 
ity of  the  eye,  we  use  the  so-called  artificial  leech,  invented 
by  Heurteloup,  in  which  the  skin-wound  is  produced  by  a 
quickly  revolving  cylindrical  concave  knife,  the  blood- 
suction  by  a  glass  syringe,  in  which  the  air-attenuation  is 
obtained  by  raising  up  the  piston,  after  pressing  the  syringe 
close  to  the  skin. 

While  the  cups  can  only  be  applied  to  large  flat  surfaces, 
capillary  bleeding  of  small  and  very  uneven  places  (abdo- 
men, forehead,  temples,  regio  mastoidea  and  regio  sub- 
occipitals, gums,  mouth  of  the  womb,  etc.),  was  effected 
by  the  aid  of  a  suction-bowl,  constructed  on  the  principle 
of  the  dwarf-cup,  and  that  species  of  leech  which  has  six 


SURGICAL   EMERGENCIES.  57 

brown  stripes  at  the  neck  (hirudo  officinalis).  The  spot 
where  the  leech  is  to  bite  must  be  well  cleansed  and 
touched  with  milk  or  a  sugar  solution,  or  a  little  puncture 
of  the  skin  is  made  with  the  lancet.  To  cause  the  leech  to 
drop  off  we  strew  some  common  salt  on  the  end  of  his  tail. 
We  must  use  test-tubes  to  set  the  leeches  to  the  gum  or 
the  mouth  of  the  womb.  It  is  also  best  to  draw  a  thread 
through  the  tail  of  the  leeches,  and  to  watch  them  closely, 
so  that  they  do  not  drop  off  from  the  appointed  spot  and 
bite  at  another — the  larynx,  for  instan'ce,  as  has  been  ob- 
served. The  sucking  of  leeches  easily  becomes  painful,  par- 
ticularly in  those  territories  of  the  skin  which  abound  in 
nerves.  It  is  estimated  that  a  leech  draws  about  8  grams  of 
blood,  which,  with  an  after-bleeding  of  two  hours,  amount- 
ing in  all  to  about  15  grams,  is  decidedly  too  low  an  estimate. 
The  after-bleeding  was  formerly  assisted  by  the  application 
of  warm  cataplasms  to  the  wound.  In  order  to  increase 
the  activity  of  the  leech  they  used  to  cut  off  his  tail,  after 
the  example  of  Miinchhausen's  horse,  cut  in  two  by  the 
closing  of  the  city  gate.  It  is  much  less  cruel,  and  does  not 
at  all  interfere  with  the  vitality  of  the  animal,  to  open  the 
gastric-bags  on  its  two  sides,  as  Beer  recommended. 
(Bdellotomy.) 

The  leech-bites  often  continue  to  bleed  undesirably  long; 
it  is  true,  the  bleeding  may  mostly  be  stopped  by  continu- 
ous compression.  But  on  spots,  where  such  is  either  im- 
possible or  inconvenient,  we  shall  be  compelled  to  resort  to 
a  circumsuture-ligature  of  the  leech-bite,  or  to  puncture  of 
the  main  eminence  produced  by  the  suction  of  the  leech, 
in  the  centre  of  which  the  bite  is  bleeding.  We  do  this 
with  the  aid  of  a  needle,  which  is  drawn  through  the  base 
of  the  eminence,  around  which  we  then  wind  a  thread,  in 
8-shaped  twists,  as  was  done  in  the  sutura  circumvoluta. 

The  theory  of  transfusion  is  difficult  of  representation. 
There  is  scarcely  another  subject  on  which  we  meet  with 
so  much  fanciful  speculation,  so  much  that  is  unscientific, 
so  much  uncritical  credulity,  and  so  much  carelessness.  To 
search  in  this  haystack  for  the  scientific  needle,  and  to 
evolve  the  practically  useful  principles,  shall  now  be  our 
task. 

Even  the  history  of  transfusion  shows  us  so  indistinct  a 

Michel  Rosa,  Lettre  fisiologiches  Napoli,  1783.  Paul  Scheel,  Die 
Transfusion  und  Einspritzung  der  Arzeneien  in  die  Adern.  2  vols, 
Copenhagen,  1802  and  1803. 


58  SURGICAL  EMERGENCIES. 

picture  of  obscure  tendencies  and  ambiguous  indications, 
that  the  actual  history  of  the  development  of  the  doctrine 
of  transfusion  begins  in  fact  only  with  the  latest  acquisi- 
tions to  our  knowledge  of  the  physiology  of  the  blood. 

We  best  distinguish  four  larger  historical  periods. 

The  oldest,  which  finds  its  sources  in  the  description  of 
Greek  and  Roman  poets  (Ovid's  Metamorphosis,  lib.  vii.) 
and  starts  from  the  legend  of  the  transfusion  of  blood  with 
which  Medea  is  said  .to  have  rejuvenated  the  father  of 
Jason.  This  is  the  mythological  period.  The  second,  the 
mystic  period,  reaches  to  the  17th  century  after  Christ,  and 
included  all  the  rude  attempts  to  produce  by  infusion  of 
nutritive  and  medicinal  substances,  and  also  of  blood,  into 
the  vascular  system,  certain  changes  either  in  the  character, 
or  the  disposition  of  the  mind  of  the  respective  individual. 
These  Changes  savored  only  too  often  of  the  miraculous. 

The  third  period  reaches  into  the  beginning  of  our  present 
century  :  it  is  the  empirical,  excelling  by  controlling  animal 
experiments,  which  were  undertaken  by  men  in  whose 
science  confidence  may  be  placed,  and  who  were  universally 
held  in  high  esteem.  In  France  Denis  and  Emmereygave 
the  first  impulse  to  scientific  discussion  of  the  question  of 
transfusion;  indeed,  it  was  partly  due  to  them  that  this  sub- 
ject occupied  for  a  long  time  the  scientific  minds  and  learned 
societies  in  England  as  well  as  in  Italy.  In  England  the 
experiments  made  by  Clarke,  Lower,  King  and  Boyle  with 
scientific  judgment,  deserve  special  mention,  while  in  Italy 
Michel  Rose  made  interesting  observations  on  the  exchange 
of  blood  between  different  species  of  animals.  He  also  dis- 
covered that  large  quantities  of  blood  can  be  injected  into 
the  vessels,  and  that,  even  if  no  previous  phlebotomy  has 
been  made,  }^et  plethora  is  in  no  manner  observed  in  the 
subject  of  the  experiment. 

Transfusion  soon  fell  again  into  disrepute,  and  indeed 
from  very  plain  reasons,  when  they  began  to  use  it  for  all 
possible  chronic  and  even  psychic  diseases  (as  in  lyssa  hu- 
mana,  cancer,  febris  putrida).  And  first  through  Bischoff,* 
Prevost  and  Dumas, f  Panum,J  Brown-Sequard  §  et  al.,  by 

*  Bischoff,  M uller's  Archiv,  1835.     Vol.  II.,  page  354. 

f  Dumas  et  Genieve  T.  17  and  Ann.  de  Chemie.   T.  18  p.  294. 

\  Panum,  Experimentelle  Untersuchungen  tiber  Transfusion,  etc.  Vir- 
chow's  Archiv.  1S63.       Bd.  27. 

§  Brown  Sequard,  Comptes  rendus  de  la  soc.  de  biologie,  1849,  1850, 
1851,  of  the  Acad,  de  Sciences,  1851,  1855  and  1857;  ^so,  jour,  de  phy- 
siol.  T.  I. 


SURGICAL   EMERGENCIES.  59 

their  partly  historic  and  partly  chemical  studies  on  blood,  the 
doctrine  of  transfusion  entered  its  fourth  and  scientific 
period,  which  we  shall  briefly  call  the  modern. 

Here  we  meet  for  the  first  time  the  important  knowledge, 
that  it  is  the  red  blood-discs  which  constitute  the  important 
factor  of  transfusion,  and  that  only  arterial  or  arterialized 
blood  possesses  vivifying  power. 

The  utility  of  defibrinated  blood  and  the  greater  facility 
for  its  injection  contributed  materially  to  the  popularization 
of  transfusion,  and  forced  the  use  of  the  formerly  favored 
animal  blood  quite  into  the  back-ground.  Human  defibrin- 
ated blood  has  since  received  exclusive  preference.  Thus 
Blundell  *  transfused  in  puerperal  haemorrhage  and  puer- 
peral fever.  Waller  f  in  chronic  anaemia,  Neudorffer,  after 
prolonged  suppuration,  in  chronic  pyaemia,  Polli  in  neuropa- 
thies, DieffenbachJ;  in  cholera,  Blasius§  in  leucaemia,  Traube|| 
and  Martin^  in  carbonic  oxide  gas  poisoning.  But  as  Mar- 
tin %  had  successfully  employed  non  -  defibrinated  human 
blood,  the  question  was  again  discussed  whether  preference 
should  be  given  to  beaten  (defibrinated)  blood  or  to  not- 
beaten  (complete)  blood.  Violent  disputers  urged  the  loss 
of  vitality  of  defibrinated  blood,  and  the  fear  of  introducing 
coagulain  its  use.  Though  no  scientific  proof  was  offered 
in  support  of  the  above  allegations,  they  were  important 
factors  in  the  resumption  of  the  employment  of  intact  (non- 
defibrinated)  blood.  And  thus  also  the  recently  recom- 
mended transfusion  of  animal's  (lamb's)  blood  was  exten- 
sively employed.  Yet  it  was  soon  discarded,  because  the 
sanguine  expectations  which  were  attached  to  it,  especially 
in  chronic  affections  (particularly  phthisis)  were  by  no 
means  fulfilled. 

Previous  to  formulating  our  attitude,  and  designating  the 

*  Blundell's  Vorlesungen  liber  Geburtshilfe,  by  Thomas  Castle,  transl. 
by  L.  Caiman,  Leipzig,  1838,  complete  ;  also,  Cline's  Articles  in 
Medico-chirug  Transactions.     Vol.   IX.  Part  I.    1818. 

f  Waller,  Diss,  inaug.  med.  de  sanguinis  in  periculosa  hsemorrhagia 
uterina  transfusione.      Erlangen,  1832. 

X  Dieffenbach,  Die  Transfusion  des  Plutes,  etc.  Berlin,  1828,  and  Die 
operative  Cherurgie,  1845.     Bd.    I. 

§  Blasius,  Monatsblatt  fur  med.  Statistik  Beilage  zur  deutchen  Klinik. 
18C3. 

||  Friedberg,  Die  Vergiftung  urcdh  Kohlendunst.  Berlin,  1863.  Martin 
und  Barth,  Verhandl  d.  Berlin  med.  Gesellschaft  1867. 

^  Martin,  Ueber  die  Transfusion  bei  Blutungen  Neuentbundener. 
Berlin,  1859. 


60  SURGICAL  EMERGENCIES. 

really  practical  methods,  we  will  briefly  recapitulate    the 
procedures  which  have  been  proposed  and  executed. 

According  to  the  form  in  which  blood  is  used,  we  dis- 
tinguish: 

1.  Transfusion  of  intact  (not  defibrinated)  blood. 

i.  Conduction  into  the  vein  of  the  recipient  directly  from 
the  vein  of  the  donor  by  means  of  special  apparatus  (Rous- 
sel,*  veno-venous  transfusion).    • 

2.  Conduction  of  blood  obtained  by  venesection,  which  is 
introduced  into  the  recipient's  vein  by  pumping  apparatus 
(Moncocq,f  Collin,  Mathieu)  or  syringes   (Martin,  /.  c). 

3.  Transfusion  of  capillary  blood  (obtained  by  cupping) 
by  means  of  pumping  it  into  the  vein  (Gessellius  J). 

4.  Transference  from  artery  to  artery  by  pumping 
(Schliep,§  arterio-arterial  tranfusion). 

5.  Direct  transfusion  from  artery  to  vein.  As  yet  this 
procedure  has  been  employed  only  by  using  the  carotid 
artery  of  the  lamb  directly  into  the  human  median  basilic 
vein. 

II.  Transfusion  of  defibrinated  blood  (almost  exclusively 
that  of  man): 

1.  Into  veins,by  syringes  (Landois,||  Uterhart,^[  Braune**) 
or  with  the  use  of  simple  receptacles  for  measurement)  Na- 
gel,  Casse).ff 

2.  Into  arteries  (Hueter'sJJ  periphero-arterial  injection  of 
blood.) 

We  distinguish,  according  to  the  donor  :  A.  Transfusion 
of  the  blood  of  the  same  species  (man  to  man).  To  this  di- 
vision belong:  (a)  Most  of  the  transfusions  with  defibrin- 
ated blood;  (b)  Veno-venous  transfusion  of  non-defibrinat- 
ed  blood  (directly  from  the  vein,  or  the  product  of  venesec- 
tion, or  capillary  blood);  (c)  Arterio-arterial  transfusion 
(Schliep).     B.  Transfusion  of  the  blood  of  different  species. 

*  Roussel,  Arch,  de  l'anat,  et  de  la  physiol.  1868,  p.  552. 

f  Moncog,  Transfusion  instantanee  du  sang.      Paris,  1874. 

\  Gesellius,  Die  Transf.  des  Blutes,  Eine  Studie.  St.  Petersburg  and 
Leipzig,  1873. 

§  Schleep,  Berl.  klin.  Wochenschr,  1874.  No.  3. 

I  Eulenburg  und  Sandois,  Die  Transfusion,  des  Blutes.     Berlin,  1866. 

*[T(  Uterhart,  Berl.  klin.   Wochenschr,  1868.  No.  10. 

**  Braune,  Arch,  ftir  klin.  Chirurgie.     Bd.  VI. 

ff  Casse,  De  la  transf.  du  sang.  Mem.  presente  a  l'acad.  royale  de 
med.  de  Belgique  le  29,      Novembre,  1873. 

XX  Pueter,  Die  arterielle  Transfusion.  Arch,  fur  klin.  Chirurgie,  1870, 
Bd.  12.  S.  I. 


SURGICAL  EMERGENCIES.  6l 

— Transfusion  of  animal  blood  to  man.  This  comprises: 
(a)  All  of  those  direct  transfusions  made  with  intact  arte- 
rial blood  (see  Hasse's  Monograph  *).  (b)  A  great  part 
of  the  arterio-venous  transfusions  of  intact  blood,  by  means 
of  pumping  apparatus;  (c)  Injections  of  defibrinated  ani- 
mal blood  and  of  the  serum  of  animal  blood. 

How  shall  we  select  the  most  rational  procedures,  and 
upon  what  principles  shall  we  judge  of  their  utility?. 

The  object  of  transfusion  is  the  introduction  of  viable 
red  blood-discs,  which  are  destined  to  serve  respiration  and 
the  metamorphoses  in  general.  To  these  ends,  it  is  neces- 
sary that  the  blood-discs  be  in  a  liquid  favorable  to  their 
existence  and  that  the  recipient's  blood  be  not  of  such  a 
character  as  to  endanger  their  vitality.  It  is  well  known  that 
the  power  of  resistance  of  the  blood-discs  differs  in  dif- 
ferent animal  species,  and  that  the  serum  of  different  kinds 
of  blood  does  not  injure  the  blood-discs  of  a  number  of  an- 
imals, while  other  blood-discs  invariably  die  in  it.  These 
facts  are  of  the  greatest  possible  importance  in  transfusion 
of  animal  blood,  because  perhaps  the  blood-discs  of  the  or- 
ganism which  requires  blood  will  not  be  affected  by  the 
injected  blood  (e.g.,  lamb's  blood).  Again,  the  injected 
blood-corpuscles  can  retain  their  vitality  but  a  short  time  in 
human  blood.  Landois  f  asserts  that  the  reverse  condi- 
tion prevails  when  dog's  blood  is  employed. 

Among  other  points  which  must  be  considered,  are  the 
gaseous  constituents  of  the  blood  (Brown-Sequard,  /.  c,  and 
Panum,  /.  c).  The  dyspnoea  which  has  often  been  observed 
in  most  alarming  form  after  transfusions  with  lamb's  blood, 
has  been  attributed  to  the  large  amount  of  carbonic  acid 
which  it  contains.  This  called  forth  Traube's  proposition 
to  render  the  animals  apnceic  previous  to  performing  the 
transfusion.^ 

Alexander  Schmidt's§  investigations  of  the  fibrin-fer- 
ment and  its  tendencies  to  the  furtherance  of  coagulation, 
resulted  in  new  views  as  to  the  utility  of  defibrinated  blood. 

*  Hasse,  Die  Lamenblut  Transfusion  beim  Menschen.  St.  Peters- 
burg u.  Leipzig,  1874. 

j  L.  Landois,  Die  Transf.  des  Blutes.  Leipzig,  1875. 

\  Kiister,  Ueber  die  directe  arterielle  Thierbluttransfusion.  Verh. 
der  deutschen  Gesellschaft,  f.  Chir.  III.   Congr.  1874. 

§  Alexander  Schmidt,  Die  Lehre  von  den  fermentativesi  Geriunungs- 
erscheinungen  u.  s.  f.  Dorpat,  1876.  (Also  cites  some  original  investi- 
gations upon  which  it' is  based.) 


62  SURGICAL   EMERGENCIES. 

Coagula  within  the  circulating  apparatus,  which  have  been 
observed  after  the  transfusion  of  beaten  blood,  are  attrib- 
uted to  faulty  procedure,  especially  defective  filtering  off  and 
allowing  the  transfused  fluid  to  regain  coagula.  Thence 
the  transferred  coagula  of  fibrin  should  give  rise  to  further 
coagulation,  as  the  plugs  of  fibrin,  even  if  they  appear  as 
simple  emboli  in  a  larger  quantity,  would  not  be  followed 
by  threatening  phenomena.  A.  Schmidt  has  shown  that 
the  defibrination  of  blood  may  generate  fibrin-ferment,  and 
that,  as  soon  as  it  is  introduced  into  the  circulation,  may 
produce  multiple  coagula.  It  is  probable  that  a  febrile 
state  of,  or  septic  processes  in  the  donor,  increase  the  coag- 
ulating power  of  the  fibrin-ferment.  Possibly  similar  con- 
ditions in  the  donor  may  increase  the  quantity  of  the  fibrin- 
ferment  in  the  defibrinated  blood  (Kohler,*.)  According 
to  Kohler  the  activity  of  the  blood  containing  fibrin-ferment 
is  also  increased,  if,  upon  injection,  it  is  allowed  to  traverse 
a  peripheral  capillary  region  of  the  body,  as,  for  instance, 
injection  into  the  peripheral  end  of  an  artery,  as  Hueter  pro- 
poses for  his  arterial  transfusion.  But  periphero-arterial 
transfusion  should  preclude  the  introduction  of  coagula 
into  the  vessels,  as  the  capillary  net  would  intercept  them. 
Aside  from  the  fact  that  the  difficulties  of  forcing  defibri- 
nated blood  into  a  capillary  region  ofttimes  become  great 
and  even  unsurmountable,  which  may  be  attributable  to  a 
spasm  of  the  muscles  of  the  vessels  as  well  as  to  coagula- 
tion, within  these  regions,  Schmidt's  experiences  must  cause 
us  to  decide  against  Hueter's  method. 

The  danger  in  a  transfusion  of  defibrinated  blood  is  not 
in  introducing  the  retained  coagula,  but  the  fibrin  ferment 
formed  by  defibrination.  Its  activity  is  materially  increas- 
ed in  peripheral  arterial  transfusion.  Landois's  (/.  c.)  pro- 
position, to  inject  into  a  large  vein  or  the  central  end  of  an 
artery,  whenever  the  surgeon  is  compelled  to  employ  defi- 
brinated blood,  appears  far  more  rational.  This  proposi- 
tion, curiously  enough,  has  met  with  no  further  indorse- 
ment, though  it  is  easily  proven  that  blood  loaded  with 
fibrin-ferment  entirely  loses  its  coagulating  properties  as 
soon  as  it  is  injected  directly  into  an  artery,  towards  the 
heart. 

A  syringe  must  be  used  for  central   arterial   transfusion, 

*  Kohler,  Ueber  Thrombose  und  Transfusion,  Eiter  und   Sepitische 
Infection.      Inaug.  Diss.  Dorpat,  1877. 


SURGICAL   EMERGENCIES.  63 

and  ttie  danger  of  forcing  in  air-bubbles  is  not  so  great  as 
when  the  injection  is  made  into  a  vein  which  might  conduct 
the  air  into  the  right  heart. 

Venous  blood-infusion  admits  of  but  two  serviceable  pro- 
cedures, viz.,  the  direct  admission  of  the  arterial  stream  im- 
pelled by  the  vis-a-tergo  of  the  donor's  heart,  and  secondly, 
allowing  the  defibrinated  blood  to  press  its  way  into  the 
vein  by  its  own  weight  as  it  rests  in  the  measuring-recep 
tacle.  As  has  been  stated,  the  first  method  has  as  yet  been 
employed  only  in  transfusion  from  animal  to  man.  Still, 
in  an  emergency,  there  would  be  nothing  to  preclude  the 
same  procedure  in  transfusion  from  man  to  man.  A  canule 
might  be  introduced,  with  all  antiseptic  precautions,  into 
the  central  end  of  the  radial  artery  of  a  healthy  donor  and 
be  united  with  another  which  has  been  fastened  into  the 
median  basilic  vein  of  the  patient,  after  the  hand  of  the 
donor  has  been  firmly  bound  to  the  arm  of  the  recipient. 
This,  like  all  other  direct  transfusions,  may  be  performed 
without  complicated  apparatus;  easily  made  glass  canules, 
united  by  rubber  tubes,  suffice.  Preparatory  filling  of  the 
canules  with  an  indifferent  liquid  is  unnecessary.  A  sound 
inserted  between  the  peripheral  canule  (7.  e.  the  one  in  the 
vein)  and  the  rubber  tube,  amply  suffices  to  prevent  the  in- 
troduction of  air,  the  operation  being  performed  as  follows: 
while  the  vein  is  still  tied  the  artery  is  opened,  and  the 
blood,  shooting  into  the  canule,  crowds  out  the  air  before  it. 
As  soon  as  drops  of  blood  instead  of  air  issue  at  the  side 
of  the  sound,  it  is  to  be  withdrawn,  as  then  the  connections 
are  filled  with  blood.  All  that  is  requisite  then  is  to  loosen 
the  ligature  which  confines  the  veins,  and  the  arterial  blood 
will  flow  unimpeded  into  the  venous  territory  towards  the 
heart.* 

Direct  conduction  from  artery  to  artery  will  be  found 
possible  only  in  those  cases  in  which  the  arterial  tension  of 
the  donor  is  greater  than  that  of  the  receiver.  Thus,  in  a 
profound  anaemia  it  might  be  essayed,  transfusing  blood 
directly,  that  is,  through  simple  canules  from  the  central 
end  of  an  artery  of  the  donor  into  the  peripheral  end  of  the 
artery  of  the  receiver.  When  the  tension  of  both  arterial 
systems  is  equal,  the  effort  will  prove  futile.  In  the  human 
being  these  transfers  have  as  yet  been  made  only  by  means 

*  V.   Transfusion  unci   Autotransfusion.     Sammlung  klin.   Vortrlige, 
No.  86. 


64  SURGICAL  EMERGENCIES. 

of  pumping  apparatus  (Schliep  /.  c).  If  it  be  decided  to 
employ  such  a  forcing  apparatus  at  all,  we  would  recom- 
mend central  transfusion,  /.  e.,  from  the  central  end  of  the 
donor's  artery  to  the  central  end  of  the  receiver's,  as  being 
a  method  of  easier  execution. 

Formerly  syringes  were  used  for  the  introduction  of  de- 
fibrinated  blood  into  the  veins.  But  far  simpler  and  less 
dangerous  than  thus  to  force  in  the  blood,  is  to  allow  it  to 
flow  in,  impelled  only  by  its  weight  and  the  pressure  it 
exercises  upon  the  vessel  which  contains  it.  There  is  no 
danger  if  the  blood  carry  with  it  a  few  isolated  air-bubbles, 
especially  when  the  transfusion  is  made  into  a  vein  distant 
from  the  heart,  as  are  the  veins  of  the  extremities.  But 
when  a  syringe  is  used,  the  force  to  be  employed  for  the 
injection  of  each  quantity  of  blood  cannot  be  so  exactly 
calculated  as  to  assure  against  overfilling  the  right  heart, 
with  consequent  phenomena  of  engorgement  in  the  large 
venous  trunks  or  even  a  direct  forcing  of  blood  into  the 
latter,  as  for  instance  the  portal  system.  Experiments  made 
in  this  procedure  have  yielded  observations  of  haemorrhage 
into  the  intestines  and  liver,  even  to  the  extent  of  tearing 
the  latter  organ  (Casse,  /.  c). 

The  danger,  resulting  from  the  introduction  of  air  into 
veins  have  had  their  fatal  issues  explained  in  many  ways. 
First,  it  is  claimed  that  the  air-bubbles  which  arrive  into 
the  heart  are  forced  thence  into  the  lungs  and  there  pro- 
duce a  stoppage  in  the  capillaries,  with  marked  hindrance 
to  the  pulmonary  circulation.  But  Lowenthal,*  has 
shown  that  animals  subjected  to  the  injection  of  large  syr- 
ingefuls  of  air  into  the  peripheral  veins  bear  the  operation 
quite  well.  Furthermore,  it  is  known  that  even  an  inunda- 
tion of  the  pulmonary  circulation,  as,  for  instance,  with  emul- 
sions of  fat  or  wax,  is  not  followed  by  any  direct  danger  to 
life. 

Panum  and  others  have  assumed  not  only  these  impedi- 
ments to  the  pulmonary  circulation,  but  also  a  similar  cir- 
culatory disturbance  within  the  brain,  and  those  nervous 
centres  which  are  prolonged  into  the  spinal  marrow.  This  can 
be  demonstrated  experimentally  and  graphically  (Coutyf), 
especially  when    air  is   gradually  forced    into    the   veins. 

*  Loewenthal,  Ueber  die  Transfusion.     Inaug.  Diss.  Heidelberg,  1871. 
f  Couty,  Etude  experim.  sur  l'entree  de  l'air  dans  les  veines.     Paris, 

1875. 


SURGICAL  EMERGENCIES.  ^65 

Yet  those  cases  in  which  sudden  death  follows  the  admission 
of  air,  show  that  the  primary  cause  is  found  in  a  pure  arrest 
of  the  heart's  action  and  must  be  taken  into  consideration 
in  connection  with  such  fatal  mishaps  as  may  occur  in  trans- 
fusions. 

The  valves  of  the  heart,  of  which  the  tricuspid  is  most 
important  in  this  connection,  are  destined  to  arrest  fluids 
or  let  them  pass.  If  air  instead  of  blood  enters  the  heart, 
the  valves,  especially  the  tricuspid,  become  insufficient  in 
proportion  to  the  abnormal  distension,  the  degree  of  which 
depends  upon  the  quality  of  air  and  blood  which  have  en- 
tered the  heart.  The  contractions  of  the  distended  heart 
are  not  capable  of  propelling  the  blood  to  the  pulmonary 
vessels  and  beat  the  blood  in  its  right  side  to  a  froth.  Owing 
to  the  valvular  insufficiency  the  abnormal  contents  of  the  right  heart 
are  thrown  to  and  fro  between  the  pulmonary  artery  andvenoz  cavoz. 
But  few  bubbles  of  air  or  froth  reach  the  pulmonary  circu- 
lation and  the  coronary  vessels.  The  air-bubbles  do  not 
prevent  the  blood  from  entering  the  lungs  and  nutrient 
vessels  of  the  heart,  but  the  valvular  insufficiency  allows 
no  blood  to  flow  into  the  heart  from  the  venae  cavae. 
Thus  the  entrance  of  air  into  the  heart  kills  by  primary  pa- 
ralysis of  the  organ,  provided  that  large  quantities  have 
entered  at  once.  When  small  quantities  of  air  enter  the 
heart  slowly,  the  blood  which  enters  with  it  prevents  the 
rapid  death  of  the  heart-muscles  and  does  not  give  rise  to  a 
definite  interruption  of  the  pulmonary  circulation.  If,  after 
longitudinally  dividing  the  sternum  of  an  animal,  the  heart 
be  exposed  without  opening  the  pleura,  and  air  be  allowed 
to  enter  the  heart  through  a  wound  in  the  jugular  vein,  the 
ineffectual  efforts  of  the  heart  to  contract  upon  its  contents 
become  evident.  Gradually  the  coronary  vessels  fill  with 
air  or  bloody  froth  and  soon  contractions  cease  entirely.  If 
then  an  indifferent  fluid,  say  a  one  half  per  cent  chloride  of 
sodium  solution,  be  injected  by  a  fine  instrument  through 
the  heart-muscle  directly  into  the  right  ventricle  to  such  an 
extent  as  to  overbalance  the  air  in  quantity,  the  following 
phenomena  will  be  observed  :  the  contents  of  the  heart  are 
gradually  pushed  forward  by  weak  contractions,  as  the 
valves  again  become  sufficient  ;  soon  blood  follows,  the 
cardiac  impulse  becomes  stronger  and  the  pulmonary  cir- 
culation is  re-established.  Further  investigations  will  be 
required  to  demonstrate  to  what  extent  and  in  what  manner 
the  above  observations   may  be  practically  applied,  and 


66  SURGICAL  EMERGENCIES. 

whether  at  all  life-saving  results  will  be  attainable  in  sud- 
den deaths  from  the  entrance  of  air. 

We  will  now  mention  two  methods  which  have  been 
essayed  as  substitutes  for  the  injection  of  blood  into  the  ves- 
sels, viz.:  Subcutaneous  injection  of  blood  and  injection 
thereof  into  the  abdominal  cavity. 

Both  methods,  whether  intact  or  defibr-inated  blood  is  used, 
yield  absorption  of  the  red  blood-discs  by  the  circuitous 
route  of  the  lymphatics.  Thus  the  red  discs  enter  the  circu- 
lation indirectly  and  but  slowly,  therefore  these  methods 
are  not  available  for  those  cases  in  which  a  rapid  restitution 
of  blood  is  urgently  necessary.  Casse*  and  several  others 
have  injected  blood  subcutaneously  in  experiments  and  in 
patients,  but  the  results  were  very  doubtful.  The  sites  of  in- 
jection were  repeatedly  affected  with  abscesses.  It  is  claimed 
that  Ponfickf  injected  blood  successfully  into  the  abdom- 
inal cavities  of  three  patients.  Browicz  and  ObalinskiJ 
have  proved  the  latter  experimentally. 

In  proceeding  to  the  discussion  of  the  performance  of 
transfusion,  it  must  be  noted  that  the  vessel  into  which  the  in- 
jection is  to  be  made,  must  be  well  dissected  out  as  in  ligations;  and 
this  applies  to  veins  as  well  as  arteries.  The  use  of  canules 
to  penetrate  a  vein  through  the  skin  is  unsafe  and  may  even 
become  dangerous  when  large  arteries  are  near,  as  in  the 
bend  of  the  elbow.  After  the  artery  or  vein  has  been  dis- 
sected from  its  surroundings,  three  ligatures  are  placed 
about  the  vessel  thus  isolated,  one  peripherical  ligature  clos- 
ing the  vessel  permanently,  one  central  temporary  ligature, 
and  between  them  a  thread  with  which  to  fasten  the  infusion 
canule  into  the  vessel.  The  canule  is  inserted  into  the  ves- 
sel after  the  wall  thereof  has  been  incised  with  a  fine  scis- 
sors. The  direction  of  this  incision  is  made  diagonal  to  the 
long  axis  of  the  vessel.  After  the  transfusion  is  made  the 
temporary  (central)  ligature  is  tied  firmly,  then  the  canule 
is  extracted,  and  finally  the  vessel  is  cut  between  the  two 
ligatures.     All  arteries  into  which  transfusions  have  been 

*  Casse,  De  la  valeur  des  injections  du  sang  dans  le  tissu  cellulaire 
sonscutane,  Bull,  de  l'acad.  royale  de  med.  de  Belgique,  1879.  T.  xiii. 
3  ser.  No.  7 

f  Ponfick,  Buslaner,  artyl.  Zeitschrift,  1879.     No.  16. 

\  Obalinski,  Experimentelles  Beitrag  zur  peritonealen  Bluttransfusion. 
Przegled  lekarski,  1880.  No.  9,  art.  10  (Polish).  Compare  also :  Nikol- 
ski,  Ueber  den  Einfluss  der  Blutinfusion  in  die  Bauchhohleets.  Wratsch, 
1880.  No.  4  (Russian). 


SURGICAL   EMERGENCIES.  6y 

made  must  be  so  treated,  while  when  a  vein  is  used,  the 
canule  may  in  many  cases  be  merely  pushed  into  the  lumen 
of  the  vessel  without  securing  it  further.  After  the  canule 
is  removed  a  simple  compress  upon  the  site  of  operation  will 
suffice. 

The  choice  between  defibrinated  and  intact  blood  merits 
separate  consideration.  We  have  seen  that  the  use  of  beaten 
blood  does  not  appear  less  recommendable  because  the  fibrin 
is  removed,  but  because  fibrin-ferment  is  developed  by  the 
beating  and  may  lead  to  the  formation  of  coagula.  This 
coagulation  within  the  vessels  is  blamable  principally  for  the 
fatal  issues  of  cases  in  which  defibrinated  blood  was  trans- 
fused, and  not,  as  was  formerly  assumed,  a  consequence  of 
the  introduction  of  flakes  of  fibrin  into  the  circulation,  the 
presence  of  which  was  attributed  to  defective  filtration. 
Still  special  care  must  be  devoted  to  ensuring  thorough  filtra- 
tion. For  this  purpose  filters  of  satin,  from  which  the  siz- 
ing has  been  removed,  are  most  recommendable.  The  filter 
is  set  into  a  glass  funnel  whence  the  blood  flows  into  a  most 
carefully  cleaned  glass  vessel.  The  blood  is  best  beaten  with 
two  thick,  thoroughly  cleaned  glass  rods,  in  a  porcelain  dish 
into  which  the  blood  of  the  donor  was  received.  Too  little 
time  must  not,  by  any  means,  be  spent  in  defibrination,  lest 
secondary  coagulation  take  place  in  the  defibrinated  blood. 
The  glass  vessel  into  which  the  blood  has  been  conducted 
after  defibrination  and  careful  filtering,  need  not  be  specially 
warmed,  as  was  formerly  strenuously  urged.  No  evil  results 
have  followed  the  injection  of  blood  which  corresponded 
to  the  temperature  of  the  room,  as  Polli*  formerly,  and 
Casse  (/.  c.)  recently  proved.  Ore,f  Duranty,^  Schliep  (/.  c.) 
and  others,  have  proven  the  fact  that  when  using  intact 
blood  cold  retards  coagulation.  Therefore  they  recom- 
mend that  the  transfusion  apparatus,  after  being  filled  with 
blood  be  laid  on  ice,  previous  to  its  employment. 

When  a  syringe  is  employed  for  transfusion,  blood  must 
be  introduced  slowly  and  at  intervals,  to  avoid,  as  before 
indicated,  the  dangers  of  overfilling  the  portal  circulation, 
or  even  rupture  of  the  liver.  Yet  frequently  tenesmus,  col- 
ics and  vomiting  supervene.  These  can  be  avoided  by 
emptying  the  bowels  previous  to  the  operation. 

*  Polli,  Glorie  e  sventure  delle   transfusione.     Armali   universali  de 
medicina,  1854,  and  iu  the  Archives  gen.  de  med.  1854,    Oct.  et  Nov. 
f  Ore,  Gaz.  des  hopit.,  1865.     Decembre  30. 
%  N.  Duranty,  These  de  Paris,  i860. 


68  SURGICAL  EMERGENCIES. 

Among  the  other  symptoms  which  may  arise  at  a  trans- 
fusion, we  will  mention:  dyspricea,  which,  at  least  in  the  trans- 
fusion of  lamb's  blood,  is  attributed  by  Traube  (/.  c.)  to  its 
containing  greater  quantities  of  carbonic  acid.  The  lumbar 
pains,  which  have  been  explained  on  the  score  of  renal 
hyperemia,  as  hsematuria,  often  follow  transfusions.  Fre- 
quently a  rigor  follows  some  time  after  a  transfusion,  and 
later,  especially  after  transfusions  of  lamb's  blood,  the  entire 
skin  of  the  receiver  has  been  covered  with  violently  itching 
wheals  of  urticaria. 

What,  then,  are  the  indications  for  the  introduction  of  via- 
ble blood  into  the  circulatory  apparatus  ?  The  preceding 
considerations  will  indubitably  have  shown  you  that  a 
marked  degree  of  anamia  gives  the  principal  indication. 
We  would  also  transfuse  in  extensive  deep  burns,  as  in  severe 
cases  the  fatal  termination  is  brought  about  by  the  death  of 
a  large  number  of  red  blood-discs  (Ponfick,*  L.  von  Les- 
ser f). 

Thirdly,  transfusion  is  suggested  in  poisonings,  which,  as 
in  extensive  scalds,  alter  the  capacity  of  many  red  blood- 
discs  to  perform  their  functions  and  produce  acute  func- 
tional oligocythemia  (v.  Lesser, /.  r.)  In  this  connection 
poisoning  with  carbonic-oxide-gas  merits  serious  considera- 
tion, which  Claude  Bernard  \  compared  with  extensive  vene- 
section. Furthermore,  there  may  be  discussed  in  this  con- 
nection poisoning  with  chlorate  of  potash  (Marchand  §), 
pyrogallic  acid  (Neisser  ||)  and  nitro-benzole  (Yiidell, 
Filehne^f)  in  all  of  which  analogous  destruction  of  the  blood- 
discs  has  been  established. 

Again,  transfusion  is  demanded  in  poisonings  with  mat- 
ters which,  owing  to  their  presence  in  the  blood,  thence  influ- 
ence the  nervous  centres.  Such  are  chloroform,  opium  and 
its  alkaloids,  strychnia,  etc.  In  these  cases  it  is  necessary 
quickly  to  abstract  large  quantities  of  blood  and  thus  remove 
with  it  corresponding  quantities  of  the  noxious  substances  it 

*  Ponfick,  Amtlicher  Bericht  der  50  Naturforscherversammlung  in 
Miinchen  im  Jahre  1877,  p.  259. 

f  L.  v  Lesser,  Ueber  die  Todesursachen  nach  Verbrennungen.  Vir- 
chow's  Archiv.  Bd.  76. 

%  Claude  Bernard,  Lecons  sur  les  ahsesthesiques  et  sur  l'asphyxis. 
Paris,  1875. 

§  Marchand,  Virchow's  Archiv.  Bd.  77.  3.  Heft. 

||  Neisser,  Zeitschrift  fur  klin.  Medicin.  Bd.  I.  1  Heft. 

\  Filehne,  Ueber  die  Giftwirkungen  des  Nitrobenzols.  Brchif.  exper. 
Path,  und  Pharmakol.  Bd.  xL 


SURGICAL   EMERGENCIES.  69 

contains  The  loss  of  blood  must  be  covered  by  a  correspond- 
ing introduction  of  healthy  blood  from  without.  In  those 
intoxications  with  such  matters  as  have  been  mentioned, 
(carbonic  oxide  gas,  chlorate  of  potash,  pyrogallic  acid, 
nitrite  of  amyl— and  in  burns  as  well)  which  threaten  hie 
almost  only  through  the  death  of  the  blood-discs,  venesec- 
tion previous  to  transfusion  is  indicated  only  to  lighten 
the  labor  of  the  kidneys,  which  almost  alone  must  devote 
themselves  to  the  elimination  of  the  products  of  the  disinte- 
gration of  the  red  blood-discs.  _ 

In  accord  with  our  explanations  of  the  capacity  ot  the 
vascular  system,  depletion  previous  to  transfusion,  even  of 
great  quantities,  would,  as  is  self-evident,  be  quite  out  of 
place  in  the  anaemia  following  haemorrhages. 

Previous  to  again  directing  our  attention  to  anaemic  con- 
ditions we  must  now  mention  one  indication  for  transfusion, 
which  we  intentionally  omitted  when  citing  the  others.  The 
history  of  transfusion  presents  frequent  reappearances  of 
the  suggestion  of  injection  of  blood  in  chronic  diseases.  As 
yet  we  know  but  little  of  the  distinctive  modifications  which 
the  functions  of  the  red  blood-discs  suffer  in  various  affec- 
tions Equally  limited  is  our  information  upon  the  influ- 
ences of  these  disturbances  upon  the  changes  which  modify 
metamorphosis  and  the  several  tissues  in  chronic  affections. 
Therefore  the  injection  of  blood  in  chronic  diseases  cannot 
be  considered  other  than  an  empirical  measure. 

We  must  likewise  decidedly  regret  the  opinion  which  occa- 
sionally is  still  uttered,  that  an  introduction  of  blood  in  star- 
vation can  elevate  nutrition.  This  view  has  been  thoroughly 
refuted  by  Casse's  (/.  c.)  experiments,  as  well  as  by  Panum's 
classical  investigations.  The  animals  which  he  had 
starved  could  in  no  manner  be  kept  alive  by  transfusion. 
The  injected  blood  at  first  increases  the  destruction  of  albu- 
men through  its  greater  oxidation,  and  owing  to  the  lack 
of  those  albuminous  matters  which  should  be  introduced 
with  normal  nutrition.  Then,  again,  we  have  demonstrated 
that  the  excessive  red  blood-discs  are  subject  to  destruction 
with  concurrent  increase  of  nitrogenous  elimination  through 
the  urine  (Worm-Muller  f).  Now,  if  we  return  to  direct 
anaemia,  we  distinguish,  in  accord  with  Worm-Muller  s  the- 


*  Panum,  Virchow's  Arch.  1864.  Bd.  29. 

\  Worm-Muller,  Transfusion  und  Plethora.     Chnstiania,  1875. 


?0  SURGICAL  EMERGENCIES. 

ory  on  the  capacity  of  the  vascular  system  (/.  c),  three  territo- 
ries of  anaemia. 

I.  Passive  anaemia  affecting  loss  of  blood  of  from  one  and 
a  half  to  two  per  cent  of  the  weight  of  the  body.  Most 
frequently  a  spontaneous  re-establishment  of  the  blood- 
constituents  takes  place,  as,  for  instance,  after  syncope,  etc. ; 
therefore  we  may  designate  this  territory  as  the  physio- 
logical stage  of  anaemia, 

II.  Anaemia  threatening  life  in  which  the  loss  of  blood  is 
as  much  as  three  per  cent  of  the  weight  of  the  blood  con- 
tained in  the  body.  As  we  have  seen  that  this  is  the  limit 
in  which  the  pressure  of  the  blood  and  the  number  of  the 
red  discs  in  it  suffer  sudden  diminution,  dependent  on  a 
peculiar  distribution  within  the  vessels,  we  will  in  view  of 
that  distribution  perhaps  be  able  to  avoid  danger  by  auto- 
transfusion  without  being  compelled  to  introduce  blood 
from  without.  Auto-transfusion  will'  shortly  be  discussed 
in  detail. 

III.  Fatal  Anozmia. — This  is  the  true  domain  of  trans- 
fusion,  in  which  it  only  and  alone  can  save  life,  because 
auto-transfusion  will  neither  bring  about  an  elevation  of 
the  blood-pressure  nor  be  able  to  reproduce  a  proper 
admixture  of  its  constituents,  which  approximates  the 
normal  condition.  (Compare  von  Lesser,  Transfusion  und 
auto-transfusion,  Sammlung  Klinischer  Vortrage,  No.  86  ; 
and  see  the  following  chapter  on  auto-transfusion). 

We  have  just  seen  that  loss  of  blood  within  a  certain 
limit  can  be  replaced  from  without  by  conducting  to  the 
heart  the  blood  which  has  been  accumulated  in  certain 
vascular  districts,  as  the  consequence  of  sudden  sinking 
of  the  blood-tension  resultant  upon  the  haemorrhages  which 
have  reached  a  certain  degree.  And  when  centripetal  ex- 
pression of  the  extremities  by  kneading  and  likewise 
pressing  the  abdomen  was  practised,  elevation  of  the 
blood-pressure  and  greater  filling  of  the  aorta  was  attained, 
as  has  been  shown  you  in  the  second  lecture.  Importance 
does  not  attach  to  blood  which  normally-is  found  in  the 
said  parts,  but  only  to  a  local  stasis,  while  the  aorta  system 
is  but  slightly  filled.  When  fatal  haemorrhage  occurs  under 
such  disturbances  of  the  blood-distribution  an  anaemic 
individual  will  die  if  the  necessary  assistance  be  not  given 
him,  and  yet  may  possess  a  sufficiency  of  blood  to  main- 
tain life  had  the  blood  been  properly  distributed.  The  patient 
dies  not  from  lack  of  blood,  butfrotn  lack  of  blood-circalation. 


SURGICAL  EMERGENCIES.  7 1 

Auto-transfusion  as  a  means  of  restoring  engorged  quan- 
tities of  blood  to  usefulness  to  the  organism  was  first  sub- 
jected to  scientific  explanation  through  the  works  of  Worm- 
Miiller  (/.  c).  It  was  long  known  and  practised  as  a 
popular  remedy,  especially  in  haemorrhages,  during  and 
after  parturition  (Hausmann*). 

The  proper  field  for  auto-transfusion  is  that  anaemia 
which  endangers  life  (second  territory).  In  this  a  key  to 
the  quantity  of  blood  of  which  the  body  can  still  dispose 
is  given  us.  As  is  self-evident,  auto-transfusion  is  most 
efficacious  in  the  lightest  forms  of  transitory  anaemia  (first 
territory).  In  those  cases  in  which  the  effect  of  auto-trans- 
fusion is  so  limited  that  for  the  purpose  of  saving  life  which 
is  being  extinguished,  we  must  bring  blood  from  without 
as  quickly  as  possible,  auto-transfusion  serves  as  a  positive 
means  of  diagnosis  to  indicate  to  us  the  quantity  of  blood 
which  we  should  introduce.  For  this  purpose  it  is  better 
and  more  reliable  than  the  symptcnvs  of  haemorrhage  which 
the  pulse  and  other  means  furnish,  as  they  depend  to  a 
great  extent  upon  nervous  reflex.  In  these  cases  also  auto- 
transfusion  will  be  of  great  use  as  a  preparation  of  the 
patient  for  transfusion.  It  also  subserves  the  purpose  of 
forcing  into  the  circulation  all  of  the  blood  which  remains 
in  the  body,  and  thus  to  sustain  life  until  the  injection  of 
blood  can  be  made. 

Furthermore,  the  execution  of  transfusion  is  recommend- 
able  in  all  cases  of  profound  anaemia  which  are  to  be  sub- 
jected to  operations  in  which  haemorrhage  is  inevitable 
(extraction  of  the  child  in  placenta-praevia  and  after, 
haemorrhage,  etc.).  Finally,  it  should  be  used  in  profound 
anaemias  previous  to  the  administration  of  chloroform, 
which,  as  is  well  known,  diminishes  the  blood-tension  and 
may  lead  to  a  deadly  collapse  in  those  who  have  been  ex- 
hausted by  loss  of  blood  (see  Koch,  Ueber  das  Chloroform 
und  seine  Anwendung  in  der  Chirurgie.  Sammlung 
Klinischer  Vortrage,  No.  89). 

Auto-transfusion  is  very  simply  executed.  The  patient 
is  placed  with  his  head  lower  than  his  pelvis.  The  extremi- 
ties are  elevated  singly  or  together  to  the  vertical  posture, 
and  either  bandaged  or  stroked  from  the  periphery  to  the 
centre.     Hereto  are  added  kneadings  of  the  abdomen  and 

*  Hausmann,  Zeitschrift  fur  Geburtshilfe  und  Grynakologie.  Bd.  I. 
Heft.  2. 


J2  SURGICAL  EMERGENCIES. 

a  progressive  pressure  on  the  intestines  from  the  symphysis 
pubis  to  the  margin  of  the  ribs  and  special  compression  of 
the  region  of  the  liver.  The  thorax  should  also  be  com- 
pressed from  time  to  time  by  pressure  upon  the  ribs  in  the 
axillary  line,  as  in  Marshall  Hall's  Artificial  Respiration, 
the  action  of  which  most  probably  favors  respiration,  but 
indirectly,  while  it  principally  facilitates  the  flow  of  blood 
to  the  right  heart.  Undoubtedly  the  action  of  direct 
mechanical  pressure  upon  the  heart  assists  in  this  pro- 
cedure (Bohm*).  From  time  to  time  the  head  should  be 
elevated  for  brief  moments  so  as  to  allow  the  blood  of  the 
jugular  veins  to  arrive  at  the  heart  more  quickly.  Nelaton's 
suspension  by  the  heels  in  the  asphyxia  of  chloroform 
belongs  to  the  domain  of  auto-transfusion. 

Note. — In  the  preceding  footnotes  no  claim  is  made  to  completeness. 
Fuller  bibliographical  reports  will  be  found  in  the  monographs  of  Scheel, 
Dieffenbach,  Martin,  Landois,  Geselius,  Casse,  and  others. 

*  Bohm,  Centralblatt  fiir  med.  Wissenschaften,  1874.  No.  21. 


SURGICAL  EMERGENCIES.  73 


LECTURE  VII. 

Impediments  to  the  supply  of  air. — Sudden  stoppage  thereof  in 
strangulation. — Foreign  bodies  in  the  trachea  and  oesophagus. — 
Perilaryngeal  swelling  of  the  tissues. — oedema  glottidis,  struma. 
Kropftod. — Gradual  narrowing  of  the  trachea  lumen. — Croup 
and  diphtheria. — Paralysis  of  the  vocal  cords. —  Tracheotomy, 
preparatory  to  other  operations. — Dilatation  of  tracheal  stric- 
tures.— Induction  of  artificial  respiration  in  chloroform  poi- 
soning,  opium  poisoning,  tetanus. — Modus  operandi. — Rapid 
and  slow  suffocation,  their  causes  and  symptoms. — Dangers 
of  suffocation  in  tunnels  and  mines;  to  divers,  aeronauts  on 
high  elevations;  working  in  compressed  air  {caissons  in 
bridge-building). — Narcosis  in  compressed  air  according  to 
Paul  Bert. — Mechanism  of  artificial  respiration. — Opening 
the  cervical  bronchus. — Pharyngotomy. —  Thyrotomy. — Thyro- 
c?  icoid  laryngotomy. — Cricotomy  or  crico-tracheotomy. — Siiper- 
glandular  and  infra-glandular  tracheotomy. — Procedures  in 
tracheotomies. — Pose's  rectangular  dissection  of  the  trachea. — 
Insertion  of  the  tube. — Removal  of  croup  membra?ies  and 
foreign  bodies. — Sucking  out  fluids  not  to  be  done  in  diph- 
theria.— Dimensions  of  tubes,  and  their  modes  of  fastening. — 
Dressing  of  the  wound  in  tracheotomy. — Painting  it  with  an 
eight-per-cent  solution  of  chloride  of  zinc. — Inhalation  through 
the  wound  of  tracheotomy. — Removal  of  the  tube. — Impedi- 
ments to  respiration  after  the  tracheotomy. — Granuloma. —  Stric- 
tures.— Posture  of  the  patient  in  tracheotomy. — Instruments 
and  paraphernalia  for  tracheotomy. 

Gentlemen:  A  study  of  the  supply  of  air  and  early 
recognition  of  its  limitations  is  as  important  a  matter  for 
the  physician,  as  is  the  arrest  of  haemorrhages.  The  correct 
interpretation  of  the  symptoms  in  respiratory  disturbances, 
as  well  as  the  rapid  removal  of  the  cause  of  disturbance,  is 
ofttimes  of  the  highest  importance  in  the  saving  of  life.  This 
is  above  all  applicable  to  the  sudden  deprivation  of  the  sup- 
ply of  air,  to  which  we  will  now  give  a  detailed  attention. 
Sudden  shutting  off  of  the  air-supply  from  the  lungs  is  pro- 
duced  either  by  a  direct   narrowing  of  the   lumen  of   the 


74  SURGICAL  EMERGENCIES. 

trachea  or  by  its  compression  from  without.  The  latter 
maybe  caused  by  constringent  power  about  the  neck,  as  in 
hanging  or  strangulation.  In  these,  if  they  be  adults  with 
ossification  of  the  laryngeal  cartilage,  we  will  find  peri- 
laryngeal haemorrhages,  contusions  and  bloody  suffusion  of 
the  bronchial  mucous  membrane,  as  well  as  frequently  injury 
to  the  laryngeal  cartilage.  In  all  injuries  to  the  laryngeal 
structures,  whether  by  gun-shot  wounds  or  blunt  missiles 
projected  against  the  anterior  cervical  region,  we  must 
always  perform  tracheotomy  to  guard  against  the  possible 
apncea  of  oedema  glottidis. 

The  tracheal  lumen  is  frequently  reduced  by  the  presence 
of  foreign  bodies.  If  these  are  firm  bodies  they  fall  down 
into  the  lower  part  of  the  trachea,  as  might  coins,  beads, 
pins  and  needles,  bits  of  bones,  etc.,  or  they  may  occlude 
the  laryngeal  entrance,  as  would  large  and  hastily  swallowed 
pieces  of  meat.  These  may  be  firmly  wedged  in  by  the 
peristaltic  action  of  the  oesophagus  (from  above  downwards) 
or  by  violent  inspiration  forced  into  the  rima  glottidis  and 
held  there  by  a  spasm  of  the  vocal  cords.  There  are  many 
cases  recorded  in  which  bits  of  meat  thus  caught  by  the 
above  mechanism  have  been  followed  by  rapid  fatal  suffo- 
cation. These  pieces  are  usually  so  firmly  wedged  in,  that 
though  the)?-  can  be  easily  reached,  the  fingers  and  even  for- 
ceps will  often  have  great  difficulty  in  removing  them,  and 
it  may  appear  impossible.  At  those  moments  the  pressure 
of  the  motions  of  deglutition  added  to  the  spasmodic  con- 
traction of  the  soft  palate,  which  both  act  upon  the  foreign 
body  from  above  downwards,  contribute  to  its  perfect  im- 
mobility. Hereto  the  circumstance  is  added  that  the  larynx 
is  pressed  tightly  against  the  posterior  pharyngeal  wall  by 
the  muscles  attached  to  the  hyoid  bone,  and  thus  contribute 
to  the  complete  closing  of  the  faucial  entrance.  The  foreign 
body  is  most  easily  made  movable  when  the  larynx  can  be 
drawn  away  from  the  vertebra.  This  is  accomplished  most 
quickly  by  inserting  a  sharp  strong  hook  in  the  center  of 
the  hyoid  bone  and  forcibly  drawing  it  towards  the  chin, 
while  a  bent  forceps  grasps  the  foreign  body  ar*d  endeavors 
to  accomplish  its  removal. 

When  foreign  bodies  have  fallen  into  the  bronchus  no 
effort  must  ever  be  made  to  remove  them  by  the  mouth. 
Aside  from  the  difficulty  of  grasping  the  foreign  body,  the 
manipulations  incidental  thereto  may  serve  only  to  force  it 
further  down  into  the   bronchial    tubes.      When  a  foreign 


SURGICAL  EMERGENCIES.  75 

body  is  in  the  trachea,  as  in  injuries  to  that  organ,  tracheotomy 
must  be  performed  as  a  prophylactic  measure  without  awaiting  the 
oedema  glottidis  which  may  supervene.  The  site  of  the  opera- 
tion should  be  if  possible  below  the  place  under  which  the 
foreign  body  is  presumed  to  rest.  Then  it  should  be  en- 
deavored to  force  it  back  into  the  fauces  by  instruments 
passed  through  the  tracheotomy-wound.  Only  when  foreign 
bodies  have  fallen  as  far  as  the  bronchial  bifurcation  will  it 
be  permissible  to  insert  forceps  or  a  spoon  (Roserf)  through 
the  wound,  which,  in  these  cases  should  be  one  of  the  infra- 
glandular  tracheotomy.  However,  instruments  should  not 
be  inserted  unless  it  has  been  found  impossible  to  dislodge 
the  foreign  body  and  have  it  fall  out  through  the  wound 
after  violent  succussion,  the  patient  being  suspended  by  the 
heels.  All  voluminous,  hard  foreign  bodies  which  are 
wedged  in  the  oesophagus  behind  the  larynx,  and  compress 
it,  call  for  tracheotomy  previous  to  making  any  efforts  for 
their  removal.  But  if  those  bodies  be  voluminous  yet  soft 
(potatoes,  dough),  they  may  be  broken  up  by  compression 
of  the  throat  by  the  points  of  the  fingers  on  both  sides  of  the 
larynx. 

Among  liquid  foreign  bodies  which  reach  the  bronchial 
tubes  through  the  larynx  and  inundate  them  should  be  men- 
tioned :  water,  in  drowning;  blood,  in  operations  on  the  facial 
part  of  the  cranium  and  in  the  naso-pharyngeal  spaces;  pus, 
upon  the  bursting  of  a  large  retro-pharyngeal  abscess,  etc. 
After  performing  tracheotomy  these  fluids  must  be  sucked 
out  as  much  as  possible. 

Sudden  closure  of  the  larynx  through  swelling  of  the  tissues 
occurs  in  oedema  glottidis,  which  we  have  already  men- 
tioned as  a  phenomenon  of  injuries  to  the  larynx,  especially 
•by  gun-shot.  It  also  occurs  after  typhus,  most  frequently 
concomitant  with  ulceration  of  the  arytenoid  cartilage  or 
necrosis  of  the  laryngeal  cartilages. 

Acute  narrowing  of  the  bronchial  tube  occurs  in  sudden 
increase  of  peri -laryngeal  swellings  or  inflammatory  swellings, 
as  also  in  rapid  pus-formation  in  Perichondritis  laryngea, 
in  Angina  Ludwigii  (phlegmone  colli  diffusa),  in  the  rapid 

*  Falk  and  H.  Kronecker,  Ueber  den  Mechanisms  der  Schluckbeweg- 
ung.  Verhandl.  der  Physiolog.  Gesellsch.  zii  Berlin,  vom  21  Mai,  1880. 
No.  13. 

f  Roser,  Vortrag  auf  dem  IX.  Congress  der  deutschen  gesellsch.  f. 
Chir.  Compare  Verhandl.  and  reference  in  the  Centralblatt.  f.  Chir.  1880. 
Supplement  to  No.  20. 


j6  SURGICAL  EMERGENCIES. 

increase  of  carotid  aneurism  or  rapid  enlargement  of  cervical 
cysts  (dermoid  cysts,  cysts  of  the  bronchial  canal,  cystoid 
lymphangiomata);  also  in  rapidly-growing  sarcomata  of 
the  cervical  lymph  glands,  and,  beyond  all,  in  the  rapid 
growth  of  strumata,  whether  they  involve  inflammatory 
swelling,  or  softening  within  parenchymatous  goitre,  or  a 
haemorrhage  into  the  cystic  goitre. 

An  enigmatical  form  of  sudden  suffocation  in  struma 
called  Kropftod,  has  been  explained  by  Rose*  as  follows: 
small,  hard,  fibrinous,  scrofulous  tumors  may  wear  away 
places  or  spots  in  the  tracheal  rings,  thus  causing  the  trachea 
to  lose  its  fine  spiral,  spring-like  frame.  Then  a  sudden 
motion  may  twist  it  upon  its  long  axis,  or  may  break  it 
through  its  transverse  axis  (Kippstenose  of  Rose). 

The  last-named  causes  which  produce  a  compression  of 
the  bronchial  canal  can  manifest  their  results  also  slowly, 
thus  producing  a  gradual  narrowing  of  the  tracheal  lumen. 
The  latter,  the  action  of  which  does  not  suddenly  cut  off  the 
supply  of  air,  but  manifests  itself  by  a  deficient  renovation 
of  the  air  in  the  lungs,  takes  place  when  swellings  grow  and 
impinge  upon  the  tracheal  entrance  as  in  fibroids  of  the 
epiglottis,  in  fibromata  which  extend  from  the  posterior  na- 
sal spine  or  in  the  often  very  vascular  tumors  at  the  base  of 
the  skull,  the  superior  maxilla  and  of  the  cavernous  retro- 
maxillary  connective  tissue  which  may  gradually  fill  the  en- 
tire naso-pharyngeal  space.  Lingual  tumors  as  well,  prin- 
cipally epithelioma,  which  extend  from  the  base  of  the 
tongue  to  the  epiglottis,  and  finally  even  swellings  and  ex- 
tensive hypertrophies  of  the  tonsils  may,  because  of  the 
gradual  impediments  which  they  offer  the  supply  of  air,  de- 
mand a  tracheotomy.  In  hypertrophies  of  the  tonsils  it  must 
be  particularly  considered,  especially  in  very  young  children 
where  the  smallness  of  the  site  of  operation  and  the  dan- 
gers of  narcosis  under  such  circumstances  preclude  the  sim- 
ple removal  of  the  enlarged  tonsils. 

The  reduction  of  the  tracheal  lumen  caused  by  patholog- 
ical processes  within  the  air-tube  merit  most  serious  con- 
sideration. 

Beyond  all  things  croup  and  diphtheria  must  here  be  men- 
tioned as  diseases  which,  at  least  in  childhood,  give  the  most 
frequent  indication  for  tracheotomy.     It  is  not  our  purpose 

*  Rose.  Ueber  den  Kropftod  und  die  Radicalcur  der  KrSpfe.  Verhandl. 
des  VI.  Cong,  der  deutsch  gesellsch.  f.  Chir.     Grosser©  Vortr.  p.  75. 


SURGICAL  EMERGENCIES.  77 

to  discuss  these  diseases  in  detail.  We  will  but  mention 
that  croup  occurs  almost  exclusively  in  the  trachea  and 
shows  finely  reticulated  membranes  and  coagulated  fibrine, 
which  rest  upon  spots  of  the  basal  mucous  membrane  which 
have  been  deprived  of  their  epithelium.  Membrane  forma- 
tion also  occurs  in  Weigert's*  pseudo-diphtheritis,  which 
is  an  extension  of  tonsillo-faucial  diphtheria  to  the  larynx. 
But  the  membranes  cannot  be  removed  during  life  without 
damage  to  the  mucous  connective  tissue  upon  which  they 
lie.  In  this  instance  the  membranes  consist  of  heaps  of  dead 
round  cells  which  exactly  resemble  those  of  the  connective 
tissue.  Besides  the  pseudo-diphtheritic  deposits,  or  often 
combined  with  them,  is  found  real  diphtheria,  that  is,  rigi- 
dity of  the  superficial  layers  or  the  mucous  stroma  itself  in 
a  mass  resembling  coagulated  fibrine  and  in  which  but  few 
or  no  visible  nuclei  are  found.  The  unnucleated  mass  shows 
more  or  less  nuclear  migratory  cells. 

The  diminution  of  the  tracheal  lumen  depends  in  these 
cases  upon  an  increased  thickening  of  the  mucous  mem- 
brane owing  to  accumulated  croup  membranes  or  through 
the  inflammatory  swelling  of  parts  of  the  mucous  membrane, 
which  are  found  beneath  the  superficial  mucous  layers 
which  have  been  killed  by  diphtheria,  otherwise  the  croup 
membranes,  which,  separate,  may  occlude  in  a  flap-like  man- 
ner and  thus  cause  sudden  suffocation.  On  the  contrary,  in 
diphtheria  the  process  may  extend  from  the  primary  bron- 
chi to  their  ramifications  within  the  lung  and  thus  reduce 
their  lumen  and  consequently  diminish  the  breathing  sur- 
face. 

Tumors  which  grow  within  the  larynx  can  bring  about 
gradual  narrowing,  as,  for  instance,  carcinoma  of  the  vocal 
cords,  in  which,  when  it  is  impossible  to  operate  on  them 
tracheotomy  would  be  in  place,  while  when  they  are  still  in 
local  limits  extirpation  of  the  trachea  should  be  performed. 
Again  benign  proliferations  of  the  tracheal  mucous  mem- 
brane, as  developed  at  the  margins  of  a  tracheal  fistula  in 
the  form  of  glandular  polyps,  may  reduce  the  volume  of  the 
trachea  partly  because  their  narrow  stem  upon  a  broad  base 
may  throw  them  upwards  with  expiration  and  thus  plug 
the  trachea,  intercepting  the  further  supply  of  air. 

Special  distinction  is  required  in  paralysis  of  the  vocal  cords. 
This  may  be  the  result  of  paresis,  of  inaction  from  contin- 

*  Weigert,  Virchow's  Archiv.  Bd.  70  and  Bd.  78.     Heft  2  (1878.) 


78  SURGICAL  EMERGENCIES. 

ued  wearing  of  a  tracheal  tube  and  where  the  tracheal  mus- 
cles have  been  subjected  to  prolonged  inactivity.  From 
these  should  be  distinguished  pareses  partly  of  central 
origin,  partly  in  consequence  of  compression  of  the 
recurrent  nerves,  as,  for  instance,  through  the  growth 
of  oesophageal  carcinoma,  or,  through  aneurism  of  the  bul- 
bus  aortse,  which  compresses  the  left  recurrent  nerve.  In 
the  latter  case  the  increasing  dyspnoea  will  finally  demand 
tracheotomy,  while  paralysis  inactivity  should  be  treated 
by  electricity. 

Strictures  of  the  trachea,  be  they  syphilitic,  traumatic  or  of 
chronic  inflammatory  origin  (Storck)  causing  increased 
dyspnoea,  demand  an  opening  of  the  trachea  below  the  con- 
striction which  will  also  subserve  the  purpose  of  gradual 
dilatation  of  the  stricture  in  allowing  the  use  of  tin  dilators 
through  the  opening  made. 

Tracheotomy  is  also  required  for  certain  special  purposes. 
Thus,  in  resection  of  the  superior  maxilla,  extirpation  of 
laryngeal  tumors  and  of  the  larynx  itself,  etc.,  it  serves  to 
chloroform  the  patient  through  the  tracheotomy  tube  and 
at  the  same  time  allows  tamponing  of  the  trachea,  thus  im- 
peding a  flow  of  blood  into  the  lungs  in  the  above-named 
operations.  The  trachea  was  occasionally  tamponed  by  means 
of  a  double-walled  rubber  hollow  cylinder  which  was  drawn 
over  the  tube  and  inflated  when  within  the  trachea.  This 
has  now  been  more  correctly  substituted,  in  resection  of 
the  superior  maxilla,  and  other  operations,  by  inducing  nar- 
cosis with  morphine  and  chloroform  and  maintaining  the 
head  of  the  patient  below  the  level  of  the  body  (Rose). 

On  the  other  hand,  we  perform  tracheotomy  when  in  the 
induction  of  artificial  respiration  an  increasing  inactivity  of 
the  respiratory  muscles  is  found.  It  is  also  applicable  in 
chloroform  and  opium-poisoning,  and  in  tetanus. 

We  have  been  taught  by  the  investigations  of  Scheinesson 
and  others  (see  Koch,  Sammlung.  Klin.  Vortr.  No.  80)  that 
chloroform  poisoning  has  as  its  most  important  manifestation 
a  primary  paralysis  of  vasomotor  nerve-centres,  evidenced 
in  considerable  depression  of  the  blood-tension,  and  have 
recommended  auto-transfusion  in  case  these  manifestations 
assume  a  threatening  character.  The  anaemia  of  the  brain- 
centres,  causing  diminution  of  the  blood-pressure  might  ex- 
plain the  transitory  paralysis  of  the  sensory  and  motor 
sphere;  while  the  centres,  which  lie  in  the  medulla  oblon- 
gata and  govern  respiration  and  the  movements  of  the  heart 


SURCICAL  EMERGENCIES.  79 

are  not  affected.  When,  however,  an  impedient  to  respi- 
ration occurs,  as  in  defective  posture  of  the  head  or  body 
of  a  narcotized  patient,  or,  as  we  will  see,  whenever  car- 
bonic acid  accumulates  in  the  blood,  then  the  centres  of 
respiration  and  circulation  are  subject  to  the  paralyzing 
influences  of  both  carbonic  acid  and  chloroform.  Auto- 
transfusion  alone  would  not  suffice,  then;  artificial  res- 
piration and  kneading  of  the  heart  (Bohm,  /.  c.)  must  be 
made  and  thus  oxidation  of  the  blood  maintained  until  a 
sufficiency  of  chloroform  has  been  eliminated.  But  auto- 
transfusion  and  artificial  respiration  must  be  persisted  in 
for  a  sufficient  length  of  time,  and  life  will  return,  though 
it  had  almost  ceased  for  half  or  even  three  quarters  of  an 
hour;  provided,  however,  that  not  too  long  an  interval 
elapsed  between  the  cessation  of  the  heart's  action  and  res- 
piration, and  efforts  at  resuscitation  have  been  begun. 

Similar  conditions  prevail  in  opium-poisoning  and  re- 
quire similar  presistance  in  the  execution  of  artificial  respi- 
ration. Opium  and  its  alkaloids  depress  the  sensibility  of 
the  various  nerve-centers,  pre-eminently  the  centre  of  res- 
piration (Filehne*).  In  this  connection  we  must  consider 
the  profound  reductions  of  sensibility  which  permit  the  ac- 
cumulation of  such  great  quantities  of  carbonic  acid,  even 
in  the  arterial  blood,  that  the  carbonic  acid  associated  with 
the  action  of  opium  can  exercise  its  paralyzing  influence 
upon  the  tissues  and  again  upon  the  functions  of  the  centre 
of  respiration  and  its  neighboring  nerve-centers.  The  neces- 
sity and  efficacy  of  artificial  respiration  in  opium-poisoning 
are  thus  rendered  self-evident.  It  should  be  continued  un- 
til the  organism  has  eliminated  a  sufficiency  of  the  poison. 
In  desperate  cases,  transfusion  should  be  tried.  Poisonings 
by  opium  occur  not  only  from  swallowing,  etc.,  of  large 
quantities,  but  also  from  painting  the  laryngeal  entrance 
with  tincture  of  opium  to  reduce  its  sensibility.  The  lat- 
ter region  seems  particularly  prone  to  produce  rapid  ab- 
sorption of  the  poison. 

You  see  here  a  rabbit,  with  which  we  will  demonstrate  the 
points  just  discussed.  It  is  lightly  bound,  and  its  carotid 
is  attached  to  a  mercurial  manometer.  We  will  administer 
chloroform  with  a  proper  inhaler.  At  the  inception  of  nar- 
cosis   and    the    incidental    excitement,   the    normal   blood- 

*  Filehne,  Ueber  d.  Einvverkung   des  Morph.  aiif  d.  Athmung.    Arch, 
f.  experius.  Pathologic  u.  Pharmakol.  1879.  Bd.  X  and  XI. 


80  SURGICAL  EMERGENCIES. 

pressure  and  respiration  are  transitorily  increased,  but  soon 
again  become  normal.  The  blood-pressure  alone  soon 
shows  a  gradual  sinking,  while  respiration,  though  it  be- 
comes somewhat  superficial,  remains  equable  and  quiet. 
After  the  animal  has  become  motionless,  and  corneal  reflex 
action  can  no  more  be  elicited,  the  pressure  sinks  lower 
and  lower  in  the  direction  of  the  lowest  point.  The  pulse- 
waves  become  smaller  and  about  one  half  less  frequent; 
respiration  becomes  deeper  and  very  frequent.  Finally  the 
pulse  is  hardly  perceptible,  and  the  respiration,  despite  its 
frequency,  appears  flatter  and  flatter.  When  the  blood- 
pressure  amounts  to  but  about  10  mm.  mercury,  the  curve 
shows  neither  pulse  nor  respiration.  If  this  condition  were 
continued,  the  individual  would  be  irretrievably  lost.  But 
we  elevate  the  animal's  legs  and  depress  its  head,  and 
while  an  assistant  exerts  pressure  upon  the  legs  and  body 
(periphero-centrally),  we  open  the  trachea  as  rapidly  as 
possible  and  induce  artificial  respiration.  Gradually  eleva- 
tion of  the  blood-pressure  occurs;  pulsation  becomes  visi- 
ble again,  and  occasionally  single,  spontaneous  inspiration 
occurs.  We  continue  auto-transfusion  and  artificial  respira- 
tion energetically;  the  number  of  pulsations  and  respira- 
tions becomes  greater,  each  respiratory  and  heart-move- 
ment stronger;  blood-pressure  rises  still  more,  sensibility 
returns  to  the  cornea — the  animal  is  saved. 

I  have  not  succeeded  in  demonstrating  an  alteration  of 
the  blood-mixture  during  depression  in  the  blood-tension 
in  a  narcotized  animal,  though  I  have  made  experiments  to 
elicit  an  increase  or  decrease  in  the  number  of  the  red 
blood-discs,  during  narcosis.  (Compare  Von  Lesser,  Die 
Vertheilung  der  rothen  Blutscheiben,  etc.) 

In  like  manner  it  could  be  shown  you  that  the  heart's 
action  and  respiration,  which  were  arrested  by  opium- 
poisoning,  can  be  re-established  by  persistent  execution  of 
artificial  respiration,  and  the  individual  called  back  to  life 
thereby.  I  beg  you  to  impress  this  advice  prominently  in 
your  minds,  and  that  you  will  not  lose  time  when  treating 
poisonings  with  the  alkaloids  of  opium,  by  the  administra- 
tion of  atropine  or  electrical  irritation  of  the  phrenic  nerve, 
but  that  you  will  tracheotomize  and  induce  artificial  respi- 
ration as  soon  as  possible.  At  the  same  time  the  above- 
named  adjuvants  may  be  applied  as  well.  When  large 
quantities  of  the  poison  have  been  taken,  and  even  long- 
continued  artificial  respiration  appears  useless,  you  must, 


SURGICAL  EMERGENCIES.  8l 

as  has  been  mentioned,  remove  goodly  quantities  of  the 
poisoned  blood,  and  substitute  it  with  approximately  equal 
large  quantities  of  the  normal  blood  of  another  individual. 

In  tetanus  as  well,  artificial  respiration,  especially  in 
acute  cases,  appears  the  only  means  which  can  be  expected 
to  maintain  life.  The  sub-acute  forms  recover,  as  we  know, 
either  spontaneously  or  as  the  result  of  the  application  of 
various,  mostly  narcotic,  remedies.  This  gives  us  a  large 
number  of  remedies,  and  the  numerous  descriptions  of  re- 
coveries under  them — chloroform,  chloral,  opium,  calabar, 
curare,  etc.  In  acute  tetanus  all  of  these  remedies  are 
useless.  Even  nerve-stretching  in  acute  cases  has  thus  far 
yielded  but  doubtful  results. 

To  thoroughly  establish  the  indications  for  tracheotomy 
we  must  elicit  in  detail  what  the  consequences  of  impeded 
respiration  would  be.  To  this  end  we  will  recall  the  inci- 
dent of  rapid  suffocation,  as  well  as  those  in  which  there 
is  gradually  increased  difficult  respiration. 

Our  atmosphere  is  composed  of  a  mixture  of  twenty-one 
parts  of  oxygen  and  seventy-nine  parts  of  nitrogen,  with 
more  or  less  contaminating  gaseous  admixture.  It  fur- 
nishes to  our  organisms — e.g.,  principally  the  blood — its 
oxygen,  and  returns  to  the  atmosphere  the  final  result  of 
the  metamorphoses — carbonic  acid.  The  exchange  of  atmo- 
spheric air  and  that  of  the  lungs  is  brought  about  by  the 
respiratory  movements.  The  renewed  air  in  the  bronchi, 
which,  when  within  the  pulmonary  alveoli,  is  brought  into 
close  contact  with  the  blood  flowing  through  the  pulmonary 
arteries, .exchanges  gaseous  constituents  by  diffusion. 

The  quantity  of  oxygen  in  serum  and  in  plasma  is  but 
slight,  perhaps  reaching  two  or  three  per  cent  in  volume. 
Serum  which  has  simply  absorbed  oxygen  can  take  up  only 
as  much  as  water  can.  Almost  the  entire  oxygen  of  the 
blood  appears  combined  with  the  haemoglobin  of  the  red 
blood-discs  as  oxyhemoglobin.  Its  percentage  is  fifteen  to 
eighteen  in  arterial  blood,  and  ten  to  five  in  venous  blood. 
This  combination  is  independent  of  the  pressure  of  the 
oxygen  in  the  atmosphere,  and  it  is  so  constant  that  whether 
respiration  takes  place  in  oxygen  or  in  atmospheric  air  the 
arterial  blood  can  take  up  no  more  oxygen.  The  quantity 
consumed  in  twenty-four  hours  is  invariable.  The  organism 
is  thus  capacitated  to  entirely  consume  the  oxygen  within 
the  space  in  which  breathing  is  performed.  If,  however, 
the  amount  of  oxygen  in  the  air  respired  is  decreased,  the 


82  SURGICAL  EMERGENCIES. 

blood  does  not  take  up  in  each  unity  sufficient  oxygen  to 
satisfy  the  coincident  need  of  the  organism  for  oxygen. 
When  eleven  per  cent  in  volume  of  the  atmospheric  air 
consists  of  oxygen,  breathing  becomes  difficult.  When  the 
percentage  in  volume  sinks  below  six,  the  limit  of  possi- 
bility of  life  therein  may  be  reached,  especially  if  respira- 
tion be  performed  in  a  closed  space  where  the  partial 
pressure  of  oxygen  rapidly  falls  to  45  mm.  mercury.  If 
the  supply  of  air  be  suddenly  interrupted,  the  oxygen  of 
the  air  in  the  lungs  will  be  almost  entirely  consumed. 
Likewise,  the  amount  of  oxygen  in  the  venous  blood  can 
sink  to  nothing. 

The  proportions  of  carbonic  acid  in  the  blood  are  de- 
pendent upon  the  proportions  of  the  carbonic  acid  in  the 
atmosphere,  subject  also  to  influences  of  the  temperature. 
Thus  we  ordinarily  find  in  the  lymph  and  serum  perhaps 
as  much  carbonic  acid  as  water  would  take  up  (100  per  cent 
at  a  low  temperature,  and  seven  per  cent  at  high  bodily 
temperature). 

The  blood  can  take  up  altogether  150  to  180  per  cent  in 
volume  of  carbonic  acid  at  a  medium  temperature  and 
barometric  pressure,  because  of  the  salts — phosphates,  car- 
bonates— which  it  contains,  loosely  combined  with  a  part 
of  the  carbonic  acid  and  bi-carbonate  of  soda.  Finally,  a 
third  part  of  the  fixed  carbonic  acid  can  leave  the  living 
blood  through  the  action  of  oxyhaemoglobin. 

The  essentials  to  an  accumulation  of  carbonic  acid  in  the 
blood  lie  in  its  saline  constituents  and  defective  arterializa- 
tion,  when  such  occurs. 

In  an  atmosphere  where  there  is  a  paucity  of  carbonic 
acid  the  blood  contains  only  such  acid  as  it  has  absorbed 
in  diffusion.  The  tension  of  C02  in  the  blood  amounts  to 
between  30-90  mm.  Hg  ;  that  in  the  atmosphere  varies  be- 
tween 25  and  60  mm.  Hg ;  thus  the  slighter  and  varying 
difference  must  be  compensated  by  the  other  forces  which 
derive  carbonic  acid  from  the  serum  if  a  sufficiently  con- 
tinued decarbonization  of  the  blood  is  to  take  place. 

The  amount  of  C02  in  arterial  blood  is  between  26  and 
30  per  cent,  in  volume,  while  the  venous  blood  contains 
about  4  per  cent.  more.  Upon  suddenly  closing  off  the 
respiratory  passages  the  amount  of  C02  in  the  blood  rises 
to  about  53  per  cent  in  volume,  but  not  higher.  The  indi- 
vidual dies  for  lack  of  oxygen  before  the  carbonic  acid  can 
exert  its  toxic  influences  upon  the  organism. 


SURGICAL  EMERGENCIES.  83 

The  conditions  are  different  when  only  the  elimination  of 
carbonic  acid  from  the  blood  is  impeded.  We  will  call  this 
impediment  "  slow  suffocation,"  which  consists  either  in  an 
accumulation  of  carbonic  acid  in  the  surrounding  atmo- 
sphere, as,  for  instance,  upon  enclosing  an  individual  in  an 
hermetically  sealed  space;  or  the  carbonic  acid  may  escape 
from  the  lungs  in  but  insufficient  quantities.  Hereto  con- 
tribute gradual  contractions  of  the  larger  air-passages,  as, 
for  instance,  in  croup  and  diphtheria,  or  it  is  owing  to  inac- 
tivity of  the  respiratory  muscles,  as  we  find  it  in  poisoning 
by  opium  or  chloroform. 

In  slow  suffocation  the  paralytic  action  of  carbonic  acid 
is  evident,  because,  despite  the  insufficient  removal  of  car- 
bonic acid,  there  yet  reaches  the  blood  sufficient  quantities 
of  oxygen.  Death  from  slow  suffocation  is  a  paralysis  in  conse- 
qiience  of  the  continually  increasing  carbonic- acid  poisoning  of  the 
nerve-centres. 

When  the  accumulation  of  carbonic  acid  is  gradual,  and 
the  atmospheric  air  contains  sufficient  oxygen,  the  stage  of 
excitement  and  convulsions  may  not  occur  and  death  may 
take  place,  accompanied  by  paralytic  manifestations  during 
apparent  subjective  health  of  the  patient.  We  should  im- 
press our  minds  with  a  very  distinct  picture  of  this  condi- 
tion, so  as  to  be  prepared  for  the  frequent  and  apparently 
unexpected  deaths  in  diphtheria.  Then  we  can  save  many 
a  young  life  by  a  properly  timed  tracheotomy,  and  will  not 
need  to  accuse  ourselves  of  having  taken  operative  meas- 
ures "  too  late"  because  of  our  defective  knowledge  of  the 
symptoms  of  gradual  carbonic-acid  poisoning. 

At  the  beginning  of  narrowing  of  the  larger  air-passages 
those  nerve-centres  which  are  still  intact  rebel  against  the 
limitation  of  the  supply  of  oxygen  through  symptoms  of 
moderate  dyspnoea  with  a  general  restlessness.  The  little 
patients  suffer  insomnia,  throw  themselves  about  and  alter- 
nate the  horizontal  position  with  the  erect.  The  deepened 
respiration  is  accompanied  by  motions  of  the  alae  nasi  and 
perhaps  also  with  contraction  of  the  scrobiculus  cordis  and 
of  the  jugulum  (fossa  suprasternalis).  But  as  the  air-tube 
contracts  still  more,  the  picture  changes.  The  nerve- 
centers,  influenced  as  they  have  been,  by  the  action  of  COa 
have  accommodated  themselves  to  the  diminished  supply 
of  oxygen.  The  child  becomes  quiet,  it  does  not  change 
its  posture  so  frequently,  notwithstanding  the  increased 
dyspnoea  and  despite  the    augmented  contractions  of  the 


84  SURGICAL  EMERGENCIES. 

thorax.  Somnolence  and  apathy  to  surroundings  occur, 
the  temperature  which  at  the  beginning  of  the  process  was 
markedly  increased,  now  shows  a  considerable  reduction 
below  the  normal.  And  thus  death  occurs  imperceptibly, 
while  breathing  becomes  flatter  and  reduced  in  frequeucy 
and  the  pulse  finally  is  but  filiform.  If  tracheotomy  be 
performed  in  this  stage  the  operator  must  be  prepared  to 
experience  a  failure,  because  of  the  advanced  paralysis  of 
the  nerve-centers  by  carbonic  acid.  Thus  the  operation 
should  not  be  deferred  beyond  the  stage  of  excitement 
unless  in  exceptional  cases. 

It  is  unnecessary  to  detail  the  symptoms  of  sudden 
suffocation.  We  have  mentioned  that  sudden  lack  of  oxy- 
gen is  the  cause  of  death.  The  nerve-centers  in  these 
instances  are  robbed  more  rapidly  of  their  vitality  after 
they  have  suffered  severe  excitement.  Thus  death  occurs 
with  violent  muscular  twitchings,  as  is  well  known  in  cases 
of  hanging. 

As  a  lack  of  oxygen  kills  nervous  apparatus  more  quickly 
than  the  gradual  action  of  carbonic  acid,  we  must  immedi- 
ately seek  an  artificial  supply  of  air  in  cases  of  sudden 
suffocation.  It  is  hardly  necessary  to  discuss  the  urgency 
of  doing  this  in  hanged  people.  Cutting  the  rope  will  not 
suffice  when  an  injury  has  occurred  to  the  tracheal  cartil- 
age ;  the  trachea  .must  be  opened  quickly.  The  same 
applies  to  foreign  bodies  in  the  trachea.  The  manner  of 
treating  them  has  been  discussed  in  detail. 

The  symptoms  of  acute  and  slow  suffocation  are  easily  demon- 
strated by  experiments.  The  signs  of  a  sudden  lack  of 
oxygen,  the  violent  disquiet  and  labored  respiratory  move- 
ments, then  the  voluntary  twitchings  of  the  extremities 
which  finally  become  a  general  convulsion  of  the  voluntary 
muscles,  are  observed  in  suddenly  closing  the  trachea  or  in 
plugging  the  tube  which  has  been  inserted  into  the  trachea. 
The  general  muscular  convulsion  is  followed  by  an  equally 
rapid  general  relaxation;  the  cornea  is  deprived  of  all 
sensation;  and  after  death  we  note  but  isolated  fibrillary 
twitchings  of  the  muscles  and  increased  peristaltic  motion 
of  the  intestines,  as  evidences  that  there  still  survives  in 


Compare  C.  Friedlander  and  E.  Herter,  Ueber  die  Wirkung  de 
Rohlensaure  auf  d.  thier  organismus.  Zeitschr.  f.  physiol.  Chemie.  Bd. 
II.  pp.  99  to  148.  And  Ibid.  Ueber  d.  Wirkung  d.  Sauerstoffmangels, 
etc.     Zeithschr.  f.  physiol.  Chemie.  Bd.  III.  pp.  19  to  51. 


SURGICAL  EMERGENCIES.  85 

the  organs  an  accumulation  of  venous  blood  which  is  over- 
charged with  carbonic  acid. 

If  we  wish  to  observe  the  consequences  of  slow  suffoca- 
tion, we  have  a  simple  means  thereto  at  hand,  viz.,  attach- 
ing an  open  rubber  tube  to  the  one  which  has  been  inserted 
into  the  trachea.  In  proportion  to  the  length  which  we 
give  the  tube;  that  is,  in  proportion  of  its  contents  to  the 
volume  of  the  expiratory  air,  the  different  degrees  of 
suffocation  can  be  produced.  If  the  space  in  the  tube  is  as 
large  or  larger  than  the  volume  of  the  expiratory  air  the 
latter  will  be  breathed  over  and  over  again.  The  entire 
volume  of  air  remains  within  the  tube  and  at  each  respira- 
tory act,  simply  moves  to  and  fro.  As  is  evident,  the 
individual  must  soon  be  suffocated.  If  we  choose  a  smaller 
tube,  we  can  allow  a  part  of  the  respiratory  air  to  escape 
and  to  be  replaced  by  atmospheric  air.  Thus,  according  to 
the  length  of  the  tube,  various  mixtures  of  expiratory  and 
outer  air  occur  and  these  serve  for  respiratory  purposes. 
However,  these  mixtures  become  poorer  and  poorer  in 
oxygen  and  richer  in  carbonic  acid  than  our  common 
respiratory  air.  As  long  as  the  blood  can  secure  sufficient 
quantities  of  oxygen  from  these  mixtures,  neither  convul- 
sions nor  disquiet  appear.  But  the  excess  of  carbonic  acid 
in  these  mixtures  causes  an  accumulation  of  carbonic  acid 
in  the  organism  which  finally  may  become  so  great  that 
the  individual  dies  under  the  paralytic  influences  of  car- 
bonic acid,  during  which  respiration  and  pulsation  are 
gradually  extinguished. 

This  simple  experiment,  which  can  be  variously  modified, 
indicates  to  us  why  permanency  in  mines  and  in  tunnels 
appears  incompatible  with  respiration,  provided  no  pumps 
are  employed  to  supply  air  to  ventilate  the  surroundings 
of  the  living  beings,  and  which  would  render  impossible 
what  we  may  call  endogenous  carbonic  acid  poisoning. 
Similar  considerations  apply  to  divers  whose  breathing-mask 
is  connected  by  means  of  a  tube  with  the  surface  of  the 
water.  But  so  as  to  supply  these  divers  with  sufficient 
oxygen,  special  pumping  apparatus  must  be  employed,  to 
furnish  air  under  a  pressure  which  will  counterbalance  the 
pressure  which  the  water  exercises  upon  the  body-surface 
of  the  diver  (Paul  Bert*). 

Furthermore,  aeronauts   and   persons  who   ascend   high 

*  Paul  Bert,  La  pression  barometrique.   Paris  1878.  p.  410. 


86  SURGICAL  EMERGENCIES. 

mountains  suffer  more  or  less  grave  symptoms,  such  as 
vomiting,  vertigo,  severe  pressing  headache,  bleeding  and 
syncope,  (Bergkrankheit),  which  depend  upon  a  lack  of 
oxygen  in  the  red  blood-discs  owing  to  a  reduced  partial 
pressure  of  the  oxygen  in  the  atmosphere  of  the  higher 
strata.  Jourdanet*  calls  this  condition  anoxyhemie  and 
considers  it  an  analogue  to  anaemia,  resultant  upon  direct 
loss  of  blood-discs. 

Other  accidents,  such  as  we  will  mention,  require  a 
different  explanation.  We  refer  to  the  workers  in  caissons 
(within  streams,  etc.),  which  are  used  in  the  construction 
of  bridges.  To  allow  such  laborers  to  work  in  the  bed  of 
the  stream,  the  atmosphere  within  the  caisson  must  be 
sufficiently  compressed  to  counterbalance  the  weight  of 
the  column  of  water  from  the  surface  to  the  ground.  The 
absorption  of  carbonic  acid  into  the  blood  is  hardly  in- 
creased thereby,  and  the  amount  of  carbonic  acid  in  the 
blood  is  not  at  all  influenced.  A  change  occurs  in  the 
quantity  of  nitrogen  which  is  taken  up  and  which  is  not 
reabsorbable.f  Its  quantity  is  increased  by  the  high 
compression  of  the  air  some  four  or  five  times.  If  the 
laborers  leave  the  caissons  suddenly,  without  subjecting 
themselves  to  a  gradual  decompression  of  the  air  in  the 
caisson  down  to  that  of  the  free  atmosphere  a  large  quantity 
of  bubbles  of  not  re-absorbable  nitrogen  are  freed  in  the 
blood  and  drag  with  them  a  part  of  carbonic  acid  in  gas- 
eous form.  The  same  applies  when  the  diver  removes  his 
breathing-mask  rapidly.  The  multiple  gas  emboli  pro- 
duce permanent  functional  disturbances  of  various  organs, 
principally  paralyses,  by  rapid  death  of  those  nerve-centers 
which  are  particularly  susceptible  to  the  consequences  of  a 
rapid  deprivation  of  blood.  In  acute  cases,  death  occurs 
by  an  accumulation  of  gas  in  the  right  heart  and  within 
the  cerebral  vessels,  just  as  would  happen  if  air  were 
suddenly  injected  into  the  veins.  In  both  these  organs  we 
find  large  quantities  of  bloody  froth  (compare  Panum  J), 
besides  which  the  heart  presents  large  quantities  of  a  mix- 
ture of  nitrogen  with  some  carbonic    acid    (P.  Bert,  /.  c). 


*  Jourdanet,  L'influence  de  la  pression.  de  l'air  sur  la  vie  de  l'homme, 
etc.     Paris,  2nd.  ed.  1876. 

f  Bert,  /.  c,  p.  964. 

X  Panum,  Experimentelle  Beitr.  z.  Lehre  v.  d.  Embolie,  Virchow's 
Archiv.  Bd.  25. 


SURGICAL  EMERGENCIES.  8? 

Hoppe-Seyler  *  mentions  the  phenomena  consequent 
upon  liberation  of  nitrogen  in  the  blood  in  rapid  decom- 
pression, as  Bert  proved  them.  Paul  Bert  (/.  c,  p.  980  and 
p.  1 148)  assumes  that  the  elimination  of  the  bubbles  of 
nitrogen  from  the  pulmonary  circulation  is  impeded  be- 
cause the  air  in  the  lungs  contains  a  very  free  admixture 
of  nitrogen  and  therefore  he  recommends  in  cases  of  too 
rapid  decompression  in  divers  and  workers  in  caissons  the 
inhalation  of  pure  and  preferably  compressed  oxygen.  He  at- 
tained good  results  in  removing  the  bubbles  of  nitrogen 
from  the  pulmonary  circulation  and  partly  from  the  heart 
of  the  animals  on  which  he  experimented.  For  the  pur- 
pose of  returning  those  bubbles  of  nitrogen  from  the 
capillaries  and  the  quantities  of  nitrogen  from  the  connec- 
tive tissue  into  the  blood,  renewed  compression  of  the  air 
{recompression)  followed  by  a  slow  decompression,  will  be  found 
the  only  useful  means.  The  same  procedure  is  recom- 
mended by  Bert,  in  entrance  of  air  into  the  veins  (compare 
Couty,  /.  c,  in  Sixth  Lecture). 

An  interesting  and  important  application  of  compressed 
air  has  been  made  by  Paul  Bert  f  in  the  narcosis  of 
nitrous  oxide  (laughing-gas).  P.  Bert  found  that  the 
simple  administration  of  laughing-gas  produces  a  very  ex- 
citing and  even  dangerous  narcosis,  owing  to  the  reduced 
amount  of  oxygen  which  is  taken  up;  therefore  he  pro- 
posed the  production  of  nitrous  oxide  narcosis  with  co- 
incident application  of  compressed  air,  so  as  to  supply  the 
the  blood  with  sufficient  quantities  of  oxygen  while  the 
anaesthetic  gas  was  being  applied.  These  narcoses,  which, 
it  is  to  be  regretted,  can  be  produced  only  in  large  estab- 
lishments which  possess  expensive  apparatus  for  the  com- 
pression of  air,  are  said  to  be  eminently  satisfactory  in  the 
course  of  anaesthesia,  as  well  as  in  the  rapidity  of  restoring 
consciousness  and  the  absence  of  all  after-effects  (vomiting, 
headache).  Even  more  extensive  surgical  operations  have 
been  essayed  under  Paul  Bert's  ingenious  procedure  (Pean,J 
Labbe,  Deroubaix  §). 

*  Hoppe-Seyler,  Ueber  d.  Einfluss,  Weichen  d.Wechsel  d.  Laftdrukes 
a.  d.  Blut  ansiibt.     Miiller's  Archiv.  1857,  p.  63  to  73. 

f  Paul  Bert,  Sur  la  possibility  d'obtenir,  a  1'aide  du  protoxyde  d'azote, 
une  insensibilite  de  longue  duree,  etc.     Comptes  rendus,  T.  87,  No. 20. 

%  Lutand,  l'Anaesthesie  par  le  protoxyde  d'azote  sans  tension.  Gaz. 
Hebdom,  1879,  No.  14. 

§  Deroubaix,  l'art  medical  de  Bruzelles,  1880.  Mai.  Compare  also 
Raphael  Blancbard,  De  l'anaesthesie  par  le  protox.  d'azote,  etc.  Paris. 
1880  (aux  bureaux  du  progres  medical). 


88  SURGICAL  EMERGENCIES. 

Previous  to  considering  the  operations  for  opening  the 
trachea  let  us  say  a  few  words  about  the  artificial  insufflation 
of  air  after  tracheotomy  and  the  changes  which  are  brought 
about  by  it  in  the  circulation.  A  reversal  of  the  propor- 
tions of  pressure  in  the  thorax  occurs  and  consequently  a 
similar  effect  is  produced  on  the  circulation.  In  contra- 
distinction to  natural  inspiration,  artificial  insufflation  of 
air  produces  a  positive  pressure  in  the  thorax  with  venous 
engorgement.  After  expiration  following  artificial  insuffla- 
tion a  negative  pressure  with  aspiration  of  the  blood  occurs 
in  the  chest  because  the  absence  of  activity  of  the  respira- 
tory muscles,  allow  the  elasticity  of  the  lung-tissues  to  ex- 
ceed that  of  the  thoracic  walls.  At  all  events  the  condition 
of  the  heart  and  the  lungs  will  have  to  be  observed  in  re- 
ference to  the  frequency  of  insufflation  of  air,  the  quantity 
of  air  to  be  insufflated  each  time  and  the  power  to  be  em- 
ployed. 

But  few  operations  of  those  which  are  performed  to  enter 
the  air-tube  from  without,  are  suitable  for  immediate  or 
permanent  supply  of  air. 

Opening  the  pharynx  by  an  incision  at  the  lower  margin 
of,  and  parallel  to  the  hyoid  bone  and  between  it  and  the 
thyroid  cartilage  (Malgaigne's  Laryngotomia  Subhyoidea 
or  von  Langenbeck's  Pharyngotomy)  is  not  proper  for  air 
supply.  Only  Vidal  recommended  it  formerly,  as  a  means 
of  catheterizing  the  larynx  through  the  opened  laryngeal 
entrance  (tubage  du  larynx?)  It  is  remarkable  that  this 
method  was  recommended  by  Hippocrates,  to  be  performed 
per  os  in  danger  of  suffocation.  It  cannot  be  indorsed 
owing  to  the  lack  of  safety  in  its  execution  and  because  it 
takes  no  consideration  of  the  locality  of  the  impediment. 
Least  of  all  is  it  permissible  to  probe  foreign  bodies  through 
the  laryngeal  opening,  when  they  are  within  the  larynx  or 
trachea. 

Desault's  thyroid  laryngotomy  is  equally  improper  for 
our  purposes  and  is  useful  only  for  the  removal  of  tumors 
from  the  laryngeal  space.  It  is  performed  by  splitting  the 
larynx  through  its  commissure  between  the  thyroid  plates. 
If  the  tube  were  to  be  inserted  between  the  thyroid  plates, 
necrosis  of  these  plates  might  easily  follow  as  might  ulcera- 
tion of  the  vocal  cords. 

The  same  applies  to  thyro-cricoid  laryngotomy  (Vicq 
d'Azy),  or  diagonal  incision  of  the  conoid  ligament,  as  it 
would  be  of  no  avail  for  permanently   wearing  a  tube,  as 


SURGICAL  EMERGENCIES.  89 

the  resultant  opening  is  too  small.  The  operation  could 
be  recommended  only  in  sudden  asphyxia  owing  to  the 
superficial  position  of  the  conoid  ligament  and  the  facility 
of  locating  it.  Inasmuch  as  the  anastomosis  of  the  thyro- 
cricoid  artery  lies  upon  the  ligament,  it  may  be  required 
to  ligate  the  artery  doubly  and  cut  it  through  its  middle, 
before  incising  the  ligament  itself.  The  dimensions  of  the 
opening  made  in  the  conoid  ligament  can  be  increased 
only  by  splitting  the  cricoid  cartilage,  but  the  wound  will, 
at  best,  serve  only  to  suck  water  out  of  the  lungs  through 
a  catheter  (as  in  drownings)  or  to  force  foreign  bodies 
which  have  fallen  into  the  larynx  back  into  the  pha- 
rynx. 

The  methods  which  are  employed  for  slitting  the  trachea 
above  or  below  the  thyroid  gland  are  of  particular  interest. 
They  are  supra  and  infra-thyroid  tracheotomies,  or,  better, 
supra  and  infra-glandular  tracheotomies. 

Supra-glandular  tracheotomy  yields  too  small  an  open- 
ing in  children  to  permit  the  introduction  of  a  tube.  There- 
fore the  orifice  in  the  trachea  is  enlarged  by  splitting  the 
cricoid  cartilage.  Then  the  tube  can  be  easily  inserted. 
The  execution  of  this  operation  is  as  follows  :  The  nail  of 
the  left  thumb  marks  the  upper  margin  of  the  thyroid 
cartilage,  whence  the  skin  is  incised  in  the  median  line  of 
the  neck  some  three  cm.  downwards,  laying  it  open  as  far 
as  the  sub-cutaneous  connective  tissue  and  exposing  the 
uniting  line  of  the  straight  cervical  muscles.  This  line 
must  be  carefully  sought  and  separated  by  two  pairs  of 
forfceps,  or  if  venous  vessels  transcourse  the  median  line  (V. 
colli  media)  it  should  be  drawn  apart  with  dull  hooks.  If 
the  indication  given  by  this  linea  alba  be  not  followed  an 
incision  might  easily  be  made  in  the  straight  cervical 
muscles  of  either  side  which  would  produce  a  much  stronger 
haemorrhage.  If  we  have  penetrated  the  middle  line  the 
trachea  will  be  exposed,  but  more  or  less  covered  by  the 
thyroid  gland,  especially  when  the  isthmus  still  exists,  and 
then  it  may  cover  the  trachea  entirely  (Lissard  *).  Formerly 
it  was  considered  necessary  to  dissect  the  thyroid  gland  off, 
to  reach  the  trachea.  This  was  frequently  accompanied 
by  considerable  loss  of  blood  and  contributed  to  prolong 
the  operation  and  increase  its  difficulties.  It  has  even  been 
proposed  to  cut  through  the  isthmus  after  doubly  ligating 

*  Lissard,  Anleitung  zur  Tracheotomie  bei  Croup.     Greesen,  1861, 


90  SURGICAL  EMERGENCIES. 

it  to  thus  expose  the  trachea  (Roser).  Bose*  merits  decided 
approbation  for  his  retro-glandular  method  of  exposing  the 
trachea,  in  which  the  thyroid  gland  is  not  dissected  from 
the  trachea  after  splitting  its  capsule,  but  it  is  levered  or 
rtther  torn  in  tact  from  the  anterior  tracheal  wall.  For 
ais,  purpose,  after  the  straight  cervical  muscles  have  been 
pulled  apart  and  the  trachea  (covered  by  the  thyroid  gland) 
is  exposed,  a  diagonal  incision  is  made  through  the  anterior 
aspect  of  the  cricoid  cartilage  at  that  place  where  the  two 
layers  of  the  deep  cervical  fascia  are  re-united  and  attached 
after  having  separated  to  form  the  capsule  of  the  thyroid 
gland.  While  the  lower  margin  of  the  slit  thus  made  is 
drawn  upwards  with  a  pair  of  forceps,  a  dull  lever  (eleva- 
tor or  handle  of  scalpel)  is  inserted  between  the  larynx  and 
the  posterior  wall  of  the  thyroid  capsule  to  tear  off  the  latter 
sufficiently.  Then  a  strong  hook  is  inserted  into  the  cricoid 
cartilage  and  drawn  strongly  against  the  chin,  out  of  the 
wound.  The  thyroid  gland  which  has  thus  been  torn  off 
with  its  capsule,  is  drawn  down  toward  the  sternum  with  a 
broad  dull  hook  or  if  necessary  a  spatula  in  the  hands  of  a 
second  assistant.  While  the  first  assistant's  right  hand 
draws  the  hook  which  is  inserted  into  the  cricoid  cartilage 
upwards,  we  place  a  large,  sharp  strabismus  hook  in  his 
right  hand  and  grasp  a  similar  one  in  our  left  hand.  Now 
the  sharp  knife  in  our  right  hand  which  is  held  closely  above 
the  protecting  plate  upon  the  thyroid  cartilage,  is  inserted 
into  the  trachea  which  it  opens  by  short,  sawing  motions 
as  far  as  the  cricoid  cartilage.  Then  the  surgeon  and  as- 
sistant insert  the  two  sharp  hooks  into  the  tracheal  wound 
and  the  surgeon,  in  case  the  trachea  is  not  sufficiently 
opened  to  introduce  the  tube,  cuts  the  cricoid  cartilage 
from  below  upwards  in  such  a  manner  as  to  liberate  the 
thick  hook  which  has  been  inserted  into  it.  The  incision 
of  the  cricoid  cartilage  converts  the  supra-glandular  tra- 
cheotomy into  Boyer's  so-called  laryngo-tracheotomy, 
which  is  also  designated  crico-tracheotomy  (Hueter). 
The  incision  of  the  conoid  ligament,  as  was  made  by  Boyer 
is  unnecessary. 

In  children  crico-tracheotomy  should  be  performed  in 
recognition  of  the  principle  that  the  tubes  should  be  as  wide 
as  possible.     The  opening  thus  made   is  so  large  that  it  is 

*  Bose,  Zur  Technik  d.  Tracheotomie.  v.  Langenbeck's  Archiv.  f. 
Klin.  Chir.  Bd.  XIV.  pp.  137  to  147. 


SURGICAL  EMERGENCIES.  QI 

not  only  adequate  for  convenient  supply  of  air  but  also  is 
useful  for  the  extraction  of  foreign  bodies  which  have 
fallen  deeply  into  the  trachea,  provided  there  is  no  swelling 
of  the  thyroid  gland.  Diagonal  incisions  at  the  upper  and 
lower  margin  of  the  tracheal  cut,  allowing  two  fateral  trac- 
heal quadrangular  flaps  to  be  opened  outwards,  as  recom- 
mended by  Dieffenbach  would  be  in  place  only  exception- 
ally when  an  abnormally  large  opening  into  the  trachea 
is  required.  In  infra-glandular  tracheotomy  the  trachea  is 
opened  from  about  its  seventh  cartilage  downwards  to 
the  upper  margin  of  the  sternum.  Some  recommend  it 
especially  in  croup  (Wilms*).  We  prefer  crico-tracheotomy 
in  children  and  people  with  short  necks.  Infra-glandular 
opening  of  the  trachea  will  be  urgently  required,  where 
there  is  a  contraction  of  the  trachea  in  the  region  of  the 
thyroid  gland,  in  enlargement  of  the  gland  or  where  foreign 
bodies  which  have  fallen  down  to  the  bronchial  bifurcation, 
are  to  be  extracted. 

Above  the  sternum  the  trachea  is  covered  only  by  in- 
tegument and  several  layers  of  the  cervical  fascia.  The 
straight  cervical  muscles  here,  are  well  separated,  especially 
in  enlargement  of  the  cervical  glands.  But  between  the 
skin  and  fascia  as  also  between  the  various  layers  of  the 
fascia  and  the  trachea  is  found  connective  tissue  often  full 
of  fat  and  still  oftener  traversed  by  an  extensive  venous  net. 
The  veins  may  be  tensely  filled  with  blood  when  there  is 
strong  dyspnoea.  Therefore  after  the  incision  through  the 
skin  from  the  sternal  notch  is  conducted  four  or  five  cm. 
upwards  in  the  middle  line  of  the  neck  the  connective  tissue 
is  carefully  split,  layer  by  layer,  as  it  is  elevated  from  the 
wound  with  two  forceps.  When  an  extensive  venous  net 
is  found  dull  hooks  should  be  used  to  crowd  the  veins  apart, 
and  the  knife  should  be  employed  as  little  as  possible. 
Furthermore,  embedded  between  the  layers  of  fascia  above 
the  sternum  a  lymph-gland  is  found,  and  in  it  a  side-branch 
of  the  thoracic  duct  terminates.  The  gland  is  often  en- 
larged. At  the  lower  margin  of  the  thyroid  gland  the 
thymus  gland  is  found  more  or  less  developed  in  chil- 
dren. In  adults  with  goitre,  enlarged  flaps  thereof  may 
hang  down  behind  the  sternum  (substernalis).  Occasi- 
onally an  arterial  branch    (arteria  thyroidea  imaj  arising 

*  See  several  Jahres  veriche  d.  krankenhauses  Bethanier  zur  Berlin 
in  v.  Langenbeck's  Archiv.  f.  Klin.  Chir. 


92  SURGICAL  EMERGENCIES. 

from  the  innominate,  courses  upwards,  along  the  trachea, 
to  the  thyroid  gland.  This  arterial  branch  must  not  be  in- 
jured. The  tearing  of  the  layers  of  the  connective  tissue 
which  cover  the  trachea  produces  emphysema  of  the  me- 
diastinal connective  tissue,  and  when  the  operation  can- 
not be  performed  with  antiseptic  precautions,  it  may  lead 
to  formation  of  pus  in  the  mediastinum,  especially  in  cases 
of  croup  or  diphtheria  of  the  trachea. 

After  exposing  the  trachea  it  is  to  be  opened  in  the 
median  line  from  the  sternum  upwards,  while  the  lower  mar- 
gin of  the  thyroid  gland  is  covered  by  a  dull  broad  hook 
and  drawn  up  to  the  chin.  During  this  incision  injury  to 
the  arteria  thyroidea  ima  must  be  avoided. 

As  to  further  procedures  upon  opening  the  treachea  at  any 
place,  the  tracheal  wound  must  be  held  open  with  sharp 
hooks  until  respiration  has  again  become  entirely  free. 
This  applies  to  drowning  and  croup,  or  until  foreign  bodies 
have  been  removed  through  the  tracheal  opening  by  long 
curved  forceps  or  by  efforts  at  coughing.  Frequently 
foreign  bodies  fall  out  of  the  trachea  when  the  patient  is 
suspended  by  the  heels.  When  sufficient  assistants  are  not 
obtainable  the  tracheal  wound  must  be  separated  by  spring 
instruments  resembling  palpebral  specula  (Bose)  or  with 
forceps  which  act  similarly  (Trousseau).  In  accumulations 
of  fluids  in  the  lungs  (blood  after  haemorrhages,  pus  after 
evacuated  retro-pharyngeal  abscesses,  water  in  drowning, 
liquor  amnii  in  premature  respiration  of  the  new-born) 
efforts  must  be  made  to  remove  them  by  means  of  deeply 
inserted  catheters  as  before  mentioned.  In  croup  the  mem- 
branes must  rather  be  removed  by  forceps  than  by  suction, 
because  of  the  irritation  and  coughing  which  it  would  pro- 
duce by  touching  the  swollen  posterior  tracheal  wall  and 
bronchial  bifurcation.  In  diphtheria  suction  is  useless  and 
reprehensible  in  the  interests  of  the  operator.  It  is  to  be 
regretted  that  it  still  figures  in  many  texts  and  is  accom- 
panied by  phraseological  praises,  as  a  life-saving  means. 
This  hare-brained  foolhardiness  has  cost  many  an  operator 
his  life,  without  saving  that  of  the  patient. 

When  there  is  no  more  dyspnoea  the  tube  is  inserted. 
This  consists  of  a  double  tube  bent  in  a  segment  of  a  circle 
having  a  movable  plate  at  one  end  to  rest  on  the  skin  of  the 
neck.  The  inner  end  of  the  apparatus  which  is  to  lie  within 
the  trachea  has  both  of  its  tubes  cut  off  diagonally  at  a  level, 
or  the  inner  one  may  project  about  i  c.m.  from  the  outer 


SURGICAL  EMERGENCIES.  93 

one,  and  be  rounded  off  like  the  point  of  a  catheter  with  a 
very  large  eye.  The  surgeon  should  be  provided  with  two 
or  three  tubes  of  diameters,  varying  from  4  to  6  m.m.,  so  as 
to  be  prepared  for  adults  as  well  as  children.  The  tubes 
are  attached  to  the  neck  by  bro<ad  tapes  which  are  drawn 
through  the  holes  of  the  movable  plate*  The  middle  of  the 
tape  is  knotted  into  the  hole  of  the  plate  at  its  anterior  part 
and  both  ends  of  the  tape  are  laid  around  the  neck  ;  the 
inner  strip  of  tape  is  drawn  through  the  second  hole  of  the 
plate  and  then  both  ends  of  the  tape  are  fastened  together 
at  the  side  of  the  neck.  The  lower  corner  of  the  incision 
can  generally  be  closed  with  a  suture.  Beneath  the  plate 
of  the  tube  a  splint-compress,  which  should  consist  of  un- 
starched guaze,  may  be  placed.  Both  halves  of  the  com- 
press should  be  sufficiently  large  to  allow  them  to  be  folded 
over  the  front  of  the  tracheotomy  tube.  The  compress  it- 
self should  be  spread  with  vaseline,  containing  either  two 
and  one  half  per  cent  of  carbolic  acid  or  twenty  per  cent  of 
boracic  acid.  Over  all  this  the  neck  should  be  enveloped 
several  times  with  a  bandage  of  unstarched  gauze,  and  over 
the  region  of  the  tube  it  should  be  moistened  with  a  weak, 
antiseptic  solution,  such  as  two  per  thousand  of  salicylic 
acid,  two  to  three  per  cent  of  boracic  acid,  aq,  plumbi  or 
diluted  vinegar.  Instead  of  these  dressings  a_mere  folded 
gauze  compress  dipped  in  an  antiseptic  fluid,  may  be  laid 
on  the  tube  and  changed  as  often  as  it  becomes  dry. 

For  several  years  I  have  been  in  the  habit  of  painting  the 
wound  with  an  eight-per-cent  solution  of  chloride  of  zinc 
during  the  tracheotomy.  I  consider  it  particularly  useful 
in  croup  and  diphtheria.  I  apply  it  at  the  moment  when 
the  trachea  is  exposed,  for  instance,  as  in  crico-tracheotomy, 
when  the  hook  is  inserted  into  the  cricoid  cartilage,  but 
previous  to  opening  the  tracheal  tube,  thus  covering  the 
fresh  wound  with  an  antiseptic  scurf  and  preventing  contact 
of  the  membranes  or  the  secretion  of  the  region  affected 
with  diphtheria.  Czerny  *  has  employed  the  same  procedure 
in  external  urethrotomy  when  made  for  impermeable  stric- 
ture. 

As  long  as  it  is  desired  to  maintain  the  tracheal  opening, 
the  outer  tube  is  left  in  it  while  the  inner  one  is  removed  as 
often  as  the  dried  secretions  or  the  extended  croup  mem- 
branes narrow  or  occlude  it.     It  may  be  cleaned  with  a  con- 

*  Neumeyer,  Inaug.   Diss.   Heidelberg,  187Q, 


94  SURGICAL   EMERGENCIES. 

centrated  solution  of  soda  and  little  brushes,  similar  to  those 
employed  for  sucking-bottles.  The  permeability  of  the 
inner  tube  must  be  closely  watched,  because  if  this  be 
neglected  dyspnoea  may  be  easily  renewed,  especially  in 
children.  In  croup,  inhalations  of  lactic  acid  (two  percent) 
with  common  salt  and  diluted  glycerine,  have  been  found 
useful  partly  to  facilitate  the  solution  of  the  membranes, 
partly  to  prevent  inspissation  of  the  secretions.  These  in- 
halations are  of  little  or  no  use  whatever  in  diphtheria. 

The  final  removal  of  the  tube  is  dependent  upon  the 
cou.rse  of  the  processes  of  infection.  The  time  for  removal 
of  the  tube  is  dependant  upon  the  course  of  the  local  pro- 
cesses such  as  may  be  influenced  by  oedema  of  the  glottis, 
perilaryngitis,  enlargement  of  the  strumous  tumor,  etc. 
Accumulations  of  fluids  in  the  lungs  allow  the  removal  of 
the  tube  sooner.  After  removal  of  foreign  bodies,  resusci- 
tation from  chloroform  and  opium  poisonings,  the  tube  can 
be  removed  immediately  and  the  soft  parts  united  by 
stitches,  which  enclose  the  tracheal  wound.  Firm  com- 
pression by  circular  bandages  around  the  neck  must  be  made 
to  prevent  the  entrance  of  air  into  the  connective  tissue  of 
the  neck.  The  time  when  the  canule  may  be  removed  after 
ft  has  been  worn  for  a  long  time  is  not  determined  by  sim- 
ply removing  it  and  observing  whether  dyspnoea  presents  it- 
self or  not.  Especially  in  children,  a  return  of  dangerous 
suffocation  wTould  bring  with  it  great  difficulty  for  the  re- 
introduction  of  the  tube.  Only  the  inner  tube  should  be 
removed.  The  outer  tube  must  have  ah  oval  opening  in  its 
upper  wall  at  the  highest  point  of  its  convexity  so  that  when 
the  outer  opening  of  the  tube  is  plugged  a  stream  of  air  can 
enter  by  the  mouth  and  nose,  Thus  the  opening  may  be 
stopped  with  a  cork  which  is  attached  to  the  outer  plate  by 
a  thread  and  the  tube  thus  closed  for  such  periods  as  the 
patient  can  bear.  Finally  the  tube  may  be  stoppered  at 
night,  and  when  it  is  worn  during  sleep  the  outer  tube  may 
also  be  removed.  This  should  never  be  done  without  having 
a  hook  at  hand  so  as  to  be  able,  iruan  emergency,  to  draw 
open  the  wound  for  the  purpose  of  re-inserting  the  tube. 

This  may  be  necessary,  though  respiration  appears  free, 
while  the  stoppered  tube  is  in  place,  still  attacks  of  suffoca- 
tion may  occur  immediately  after  the  tube  has  been  re- 
moved, or  after  the  next  violent  coughing  fit.  The  cause 
of  these  suffocatory  attacks  is  found  in  peculiar  stemmed 
proliferations  of  the  tracheal  mucous  membranes  which  are 


SURGICAL   EMERGENCIES.  Q5 

attached  mostly  to  the  lower  angle  of  the  wound,  while  their 
free  pear-shaped  end  projects  into  the  tracheal  lumen. 
These  polypi  are  forced  upwards  during  violent  expiration 
and  their  club-like  ends  plug  the  trachea.  If  they  are  cut, 
burned,  or  scraped  off  they  return  and  force  the  patient  to 
wear  a  tube  continuously.  If  a  tracheotomy  is  made  lower, 
the  old  tracheotomy  wound  heals  rapidly;  but  proliferations 
may  occur  in  the  new  wound  as  before.  As  a  rule  the 
wounds  of  tracheotomy  contract  rapidly  after,  removal  of  the 
tube.  This  contraction  can  be  facilitated  by  drawing  the  lips 
of  the  wound  together  with  adhesive  plaster  and  by  cauteriz- 
ing the  base  of  the  wound  with  the  nitrate  of  silver  stick. 
Sometimes,  perhaps  weeks  after  the  wound  has  healed, 
gradual  contractions  of  the  trachea  take  place  and  especially 
does  this  occur  after  diphtheria.  It  may  then  be  necessary 
to  reopen  the  trachea.  Even  without  any  of  the  above- 
named  causes,  the  early  removal  of  the  tube  may  be  ren- 
dered impracticable  through  a  paresis  of  the  tracheal  mus- 
cles consequent  upon  prolonged  wearing  of  a  tracheal  tube 
the  upper  surface  of  which  is  imperforate,  consequently  has 
allowed  the  tracheal  muscles  to  remain  at  rest.  In  such 
cases  direct  electrization  of  those  muscles  will  most  rapidly 
relieve  the  respiratory  insufficiency.  In  employing  it  one 
of  the  electrodes  is  set  upon  the  neck. 

In  each  tracheotomy  you  will  be  required  to  lay  the  patient 
on  his  back,  his  neck  extended  and  head  bent  back  which  is 
accomplished  by  placing  a  round  pillow,  a  rolled-up  shawl, 
or  bed-cloth  beneath  the  dorsal  aspect  of  the  neck.  The 
best  operating  table  is  a  narrow,  four-legged  one,  which 
should  not  be  too  long.  When  sufficient  assistants  are  not 
obtainable  the  patient's  feet  may  be  tied  to  the  legs  at  the 
lower  end  of  the  table,  while  his  arms  may  be  fastened  to- 
gether to  his  back,  by  cords  running  through  the  elbows. 

Two  reasons  may  be  given  why  the  physician  should  al- 
ways have  ready  in  a  special  case  the  instruments  required 
for  tracheotomy.  First,  because  when  a  tracheotomy  is  re- 
quired, no  time  must  be  lost  in  gathering  or  improvising  in- 
struments. On  the  other  hand  tracheotomy  being  required 
most  frequently  in  croup  and  diphtheria,  and  as  the  above 
processes  are  of  an  extremely  contagious  character,  it  is  well 
to  have  separate  instruments  for  that  purpose. 

The  simplest  case  may  consist  of  the  following  :  one  sharp- 
pointed  scalpel,  one  probe-pointed  scalpel,  one  dissecting 
and  two  surgical  forceps,  two  thumb-slide  forceps,  one  can- 


g6  SURGICAL   EMERGENCIES. 

ulated  sound,  two  sharp  strabismus  hooks,  two  blunt  strabis. 
mus  hooks,  one  sharp  hook  to  draw  up  the  cartilage,  two  or 
three  tracheotomy  tubes,  four  to  six  m.m.,  in  interior  diam- 
eter, one  speculum  fo»r  the  tracheal  wound,  one  pair  elastic 
catheters,  one  roll  of  tape  for  fixation  of  the  tube,  needles 
and  silk,  one  scissors,  and  one  or  two  gauze  bandages.  The 
entire  case  need  measure  but  32  cm.' in  length,  12  cm  in 
breadth,  and  five  in  height,  and  so  arranged  that  instru- 
ments may  be  placed  in  its  bottom  and  cover.  Some 
brushes  and  an  eight-per-cent  solution  of  chloride  of  zinc 
should  not  be  omitted. 


SURGICAL  EMERGENCIES.  97 


LECTURE  VIII. 

Impeded  passage  ij  alijnentary  substances  through  the  intestinal 
canal. — Impediments  in  the  pharynx  and  oesophagus: 
Topography  of  the  latter. —  The  most  narrow  points  in  the  ceso- 
phagus,  as  seats  of  foreign  bodies,  tu?nors  and  strictures. — 
Removal  of  foreign  bodies  from  the  faucial,  cervical,  and 
thoracic  parts  of  the  oesophagus. — Instruments. — CEsophag- 
Otomy. — Indications,  mode  of  procedure,  after-treatment  of 
the  wound. — Tumors  of  the  oesophagus. — Strictures,  their 
Etiology  and  treatment. — Catheterizing  the  cesophagus. 
Girard's  method. — Impediments  in  the  small  and  large 
intestines. — Hernias:  Reducible,  adherent,  strangulated. — 
Hernial  orifice,  contents,  sack,  neck;  cysts  of  the  sack. — Irre- 
ducibility,  its  etiology;  adhesions,  foecal  invagination. — Stran- 
gulation.— Acute  and  sub-acute  strangulation. — Apparent  stran- 
gulation and  its  treat?nent. — Site  of  strangulation. —  Treatment 
of  hernia. — Taxis:  Mechanisms  of  Roser,  Busch,  lossen. — 
Supporting  postures  in  taxis. — False  reduction. — Herni- 
otomy; No  special  instruments  required. — Modus  operandi. — 
Incisions. — External  and  internal  hernial  incision. — Hemi- 
otomy. — Debridement  multiple. — Repositioit  of  hertiial  con- 
tents.— Condition  of  the  loop  of  intestine. — Sutter e  of  intestine 
in  various  forms  of  gangrene. — Enteroraphy:  Treatment 
of  artificial  anus. —  Treatment  of  prolapsed  peritoneum. — 
After-treat77ient  of  herniotomy. — Radical  operation  for 
hernia. 

Gentlemen:  At  various  places  in  the  intestinal  canal 
impediments  .may  occur  which  hinder  or  render  impossible 
the  carrying  forward  of  such  matters  as  have  been  taken 
up,  digested,  or  designated  for  ejection  from  the  organism. 
Yet  you  will  find  that  with  a  great  number  of  possibilities 
in  reference  to  the  seat  of  the  impediments,  a  certain  regu- 
larity occurs,  in  so  far  as  certain  places  are  particularly 
favored  in  the  frequent  production  of  such  impediments. 
Let  us  view  the  divisions  of  the  intestinal  canal  separately, 
in  this  connection.     Where  the  pharynx  goes  over  into  the 


98  SURGICAL  EMERGENCIES. 

oesophagus  the  diagonally  striped  constrictor  (constrictores 
pharyngis)  muscles  are  substituted  by  the  smooth  muscles 
of  the  oesophagus.  The  oesophagus  extends  downward 
behind  the  trachea,  projecting  somewhat  to  the  left,  and 
within  the  thorax  runs  behind  the  trachea  and  left  bronchus, 
while  the  arch  of  the  aorta  lies  over  the  left  bronchus,  and  thus 
also  over  the  oesophagus.  This  site  belongs  to  those  points  in 
the  course  of  the- oesophagus  in  which,  most  frequently,  im- 
pediments to  the  passage  of  the  food  occur.  Other  narrow 
points  of  the  oesophagus,  we  find  behind  the  cricoid  carti- 
lage, then  behind  the  entrance  of  the  trachea  into  the 
thorax,  and  furthermore,  above  the  cardiac  space  and  at  the 
passage  of  the  oesophagus  through  its  slit  in  the  diaphragm. 

At  these  places  abnormally  large  morsels  and  foreign 
bodies  are  arrested.  We  also  see  that  at  these  places  the 
development  of  tumors,  principally  ephtheliomas,  is  most 
frequent.  They  also  are  the  most  frequent  seat  of  strictures 
which  form  within  the  oesophagus. 

Foreign  bodies  which  enter  the  oesophagus  may  first 
be  caught  in  the  glosso-epiglottidean  folds,  as,  for  instance, 
fish-bones.  Their  removal  must  be  accomplished  through 
the  mouth,  as  must  all  foreign  bodies  which  reach  the  fau- 
ces, according  to  the  precepts  detailed  in  Lecture  VII. 
Fish-bones,  especially,  are  easily  removed  by  forceps  after 
the  tongue  has  been  thoroughly  depressed  with  a  spatula. 
Bodies  which  have  lodged  deeper  are  extracted  with  special 
instruments,  among  which,  first,  forceps  are  to  be  mentioned. 
The  branches  of  the  forceps  for  this  purpose  revolve  either 
upon  their  fulcrum  or  around  their  common  long  axis,  or. 
they  are  constructed  similar  to  the  Lithotriptor,  in  which 
one  branch  is  made  to  lock  with  the  other  by  pushing  it 
forwards.  The  forceps  are  intended  particularly  for  rounded 
or  cylindrical  bodies.  Von  Graefe  constructed  a  very  use- 
ful coin-catcher  (Miinzenfanger)  for  coins  and  similar  bodies 
that  are  frequently  swallowed.  This  consists  of  a  long  staff, 
one  end  of  which  carries  two  rings,  which  are  soldered  at 
an  acute  angle.  In  inserting  this  instrument  below  the 
coins  they  promptly  fall  into  the  mould,  and  thus  can  be  re- 
moved. For  the  purpose  of  removing  deep-seated  fish- 
bones, Petit  devised  the  so-called  chain  staff  (Kettenstab- 
chen),  of  a  parachute-like  form.  The  ribs  of  the  parachute 
consist  of  movable  links  of  chain  which  easily  catch  the 
fish-bone.  Instruments  have  been  proposed  for  the  extras 
tion  of  voluminous  foreign  bodies,  which  were  to  be  opened 


SURGIGAL   EMERGENCIES.  99 

below  them,  as  in  Weiss's  whalebone  sound,  or  they  were 
to  be  removed  by  inserting  oesophageal  sounds,  the  ends  of 
which  were  provided  with  compressed  sponge,  and  the  in- 
strument was  to  be  removed  after  the  sponge  had  swelled, 
and  thus  draw  the  foreign  body  out  with  it. 

Greater  difficulties  are  experienced  in  the  removal  of 
sharp  bodies,  such  as,  for  instance,  a  fish-hook  that  has 
been  swallowed.  If  the  hook  have  a  string  or  thread  at- 
tached to  it,  balls  of  glass  or  lead  may  be  slipped  over  the 
string  as  far  as  the  hook  whereby  its  point  is  covered,  and 
lesions  of  the  oesophageal  walls  avoided  in  its  extraction. 
When  no  thread  is  attached  to  the  fish-hook  the  extraction 
must  be  made  with  one  of  the  above-named  instruments 
(coin-catcher,  chain-staff,  etc.),  but  this  always  must  be 
essayed  within  a  wide  oesophageal  sound.  This  corresponds 
to  Dieffenbach's  case,  who  removed  an  ear  of  corn  which 
was  hooked  fast  by  its  grains  to  the  vaginal  mucous  mem- 
brane. He  made  the  extraction  simply  through  a  speculum 
which  he  had  inserted.  (Compare  also  Marchetti's  case, 
cited  by  Dieffenbach  in  his  Operat.  Ghirurgie  Bd.  I.  p.  36, 
who  removed  a  dried  pig's-tail  from  the  rectum  of  a  young 
girl  in  a  similar  manner.) 

Very  soft  voluminous  bodies  can  be  broken  up  in  the 
cervical  part  of  the  oesophagus  by  a  simple  pressure  of  the 
fingers,  as  has  been  mentioned  before  (Dupuytren,  von 
Langenbeck).  When  such  bodies  are  in  the  thoracic  part 
of  the  oesophagus  they  can  be  forced  down  into  the  stomach, 
for  which  purpose  Petit's  probang  (Repoussoir)  is  useful. 
This  consists  of  an  elastic  staff  which  carries  a  sponge  at 
one  end.  Thick  oesophagus  sounds  are  equally  useful  for 
this  purpose;  while  elastic  (whalebone)  staffs  armed  with  a 
metal  ball  as  large  as  a  cherry  are  much  more  practical 
than  the  repoussoir  and  sounds,  because  they  furnish  a 
means  of  more  delicate  touch  of  the  foreign  -body  and  bet- 
ter indications  for  the  force  to  be  employed  in  projecting 
them  onward  (von  Langenbeck*). 

T£e  removal  of  foreign  bodies  from  the  oesophagus  can 
also  be  made  by  opening  it,  that  is,  by  cesophagotomy. 
This  is  called  for  as  a  direct  life-saving  operation  in  cases 
where  foreign  bodies  are  present  which  cannot  or  may  not 
be  pushed   or  extracted;  thus   in  all  voluminous,  but  not 


*  V.  Langenbeck,  Ueber  d.  Fremdkftrper  im  GEsophagus  u.  liber  de 
CEsophagotomy.  Bed.  Klin.  Wochenschr.  1877,  Nos.  51  and  52. 


100  SURGICAL  EMERGENCIES. 

compressible  objects  with  irregular,  sharp  edges  or  rough 
surfaces,  for  instance,  artificial  teeth.  Efforts  to  push  such 
bodies  upwards  or  downwards  in  the  oesophagus  might  be 
followed  by  injuries  to  the  oesophageal  mucous  membrane, 
tearing  of  its  walls,  and  even  by  rupturing  neighboring 
organs  (the  trachea,  aorta)  with  extrusion  of  decomposing 
elementary  masses  into  the  mediastinum  or  into  the  lungs, 
or  by  fatal  hemorrhage  of  the  aorta.  These  consequences 
would  also  occur  as  results  of  ulcerative  processess,  in  case 
such  foreign  bodies  were  left  in  situ.  Therefore  the  re- 
moval of  such  foreign  bodies  is  imperative,  at  all  hazards. 

Further  indications  for  oesophagotomy  are  inoperable 
tumors  in  the  cervical  part  of  the  oesophagus,  completely 
plugging  it,  and,  thirdly,  non-dilatable  strictures  in  the 
cervical  oesophagus.  Furthermore,  oesophagotomy  has 
been  performed  in  impermeable  strictures  in  the  tho. 
racic  oesophagus  for  the  purpose  of  endeavoring  to  dilate 
it  gradually  through  the  wound  (Bryk*).  This  suggests 
the  use  of  bougies  in  strictures  which  appear  impermeable 
in  the  cervical  part,  passing  said  instruments  through  the 
wound  upwards. 

The  directions  of  the  incision  in  oesophagotomy  are  the 
same  as  in  ligation  of  the  common  carotid  artery.  The  in- 
cision is  made  either  at  the  level  of  the  thyroid  cartilage,  at 
the  inner  margin  of  the  sterno-cleido-mastoid  (Guattani, 
Cooper,  Bell,  Boyer,  Richerand)  and  theomo-hyoid  is  drawn 
either  upwards  or  downwards.  Or  the  operation  is  made 
in  the  trigone  of  the  sterno-cleido-mastoid,  at  the  base  of  the 
neck,  principally  when  a  foreign  body  is  lodged  deeply  in 
the  thoracic  part  of  the  oesophagus  with  the  first-named 
incision  after  dividing  the  skin,  the  platysma  and  the  super- 
ficial cervical  fascia,  requires  the  exposure  of  the  inner 
margin  of  the  sterno-cleido-mastoid,  laying  bare  the  vascular 
sheath,  which  is  not  to  be  opened.  At  the  outer  side  of  the 
sterno-hyoid  and  under  the  deep  cervical  fascia  we  find  the 
oesophagus.  Owing  to  the  more  superficial  position  of  the 
oesophagus  on  the  left  side,  the  operation  is  always  made  on 
the  left  side.  Usually  the  walls  of  the  oesophagus  are  found 
dilated  by  the  foreign  body,  and  when  the  foreign  body  lies 
still  deeper  the  oesophageal  wall  is  forced  outward  by  the 
projecting  staff  of  the  Ektropcesophagus  (Vacca  Berling- 
heri).     A  bent  metal   catheter  or  a  lithotomy  sound  or  an 

*  Bryk.  Wiener  Med,  Wochejschr.  1877,  Nos.  40  to  45. 


SURGICAL   EMERGENCIES.  101 

oesophageal  sound  armed  with  a  mandrin,  inserted  through 
the  mouth,  may  be  used  instead  of  the  before-mentioned 
instruments. 

If  it  is  desired  to  maintain  the  oesophageal  wound  open 
for  any  length  of  time,  the  lips  of  the  wound  in  the  mucous 
membrane  are  sewed  to  those  of  the  skin  and  nutrition  must 
take  place  through  oesophageal  catheters.  If  the  mucous 
lips  are  not  sewed  to  the  skin,  inflammatory  infiltrations 
and  formations  of  pus  into  the  connective  tissue  around  the 
oesophagus  easily  occur.  If  cesophagotomy  has  been  per- 
formed only  for  the  removal  of  foreign  bodies,  the  wound 
in  the  oesophagus  may  be  closed  directly  by  sutures.  The 
wound  in  the  tissues  should  also  be  sewn  up,  but  a  drain- 
age-tube, directed  downwards,  left  in  the  wound. 

Foreign  bodies,  whose  pressure  upon  the  trachea  pro- 
duces acute  asphyxia,  must  not  be  removed  before  respira- 
tion has  become  thoroughly  free.  In  such  cases  we  must' 
follow  the  old  principle  and  first  execute  tracheotomy. 
After  this  the  foreign  body  may  be  removed  through  the 
mouth  or  through  the  wound  in  the  oesophagus. 

Tumors  of  the  oesophagus,  situated  in  the  cervical  part 
and  circumscribed. to  the  walls  of  the  oesophagus,  such  as 
circumscribed  epithelioma,  are  to  be  removed  by  resection 
of  the  oesophagus.  Tumors  developed  in  the  thoracic  part 
are  inoperable.  When  they  have  affected  the  oesophageal 
walls  in  an  annular  shape  they  result  in  strictures,  which 
finally  allow  food  to  pass  only  with  great  difficulty  or  not 
at  all.  In  these  cases  opening  the  stomach  in  the  epigas- 
trium appears  the  only  saving  means  to  prevent  death  from 
starvation.  We  will  consider  gastrotomy,  although  the 
carcinomatous  stricture  may  still  be  permeable  when  the 
passage  of  food  or  the  passage  of  the  oesophageal  sound 
through  the  stricture  furthers  the  destruction  or  stimulates 
a  more  rapid  growth  of  the  tumor. 

Tumors  occur,  for  instance,  above  the  cardia,  which  in- 
volve only  the  walls  of  the  oesophagus.  Pain  and  narrow- 
ing of  the  oesophagus  may  be  absent  and  the  tumors  dis- 
covered only  post  mortem.  Ofttimes  numerous  metastases 
are  found,  especially  in  the  liver  (the  oesophageal  veins 
communicate  directly  with  the  portal  circulation). 

Strictures  of  the  oesophagus  are  found,  as  has  been  said, 
most  frequently  at  the  same  sites  of  election  as  are  foreign 
bodies  and  tumors.  They  are  either  of  traumatic  nature, 
occurring  after  direct  injuries  of  the  oesophagus,  or  we  see 


102  SURGICAL  EMERGENCIES. 

them  formed  as  a  result  of  cauterizing  after  shedding  of  the 
slough  produced  by  the  cauterization  (swallowing  sulphuric 
acid  or  strong  alkalies.)  Diphtheritic  processes  also  ma}' 
leave  loss  of  substance,  which  by  cicatricial  contractions 
may  produce  stenosis  in  the  oesophagus.  Similar  results 
obtain  after  chronic  inflammatory  processes  of  the  oesopha- 
geal mucous  membrane,  which  appears  hypertrophic,  and 
thickened  thereby.  Spasmodic  or  hysterical  strictures  have 
been  observed,  but  these,  as  is  natural,  cede  to  the  adminis- 
tration of  chloroform.  Finally,  as  we  have  seen,  a  narrowing 
of  the  oesophagus  is  possible  from  annular  tumefaction 
within  it,  and  also  by  pressure  exercised  upon  the  oesopha- 
gus from  without,  as  in  retro-pharyngeal  abscesses,  aneur- 
ism of  the  arch  of  the  aorta,  carcinoma  of  the  spinal  column, 
sarcoma  of  the  mediastinal  lymph-glands,  etc. 

Permeable  strictures  of  traumatic  origin  are  amenable  to 
gradual  dilatation  with  sounds.  The  introduction  of  sounds 
is  made  mainly  through  the  mouth.  It  is  only  exception- 
ally that  strictures  in  the  thoracic  portion  can  be  dilated 
exclusively  by  inserting  the  oesophageal  sound  through  the 
opening  in  the  oesophagus  made  in  the  neck. 

The  introduction  of  elastic  tubes  through  the  oesophagus 
is  required  when  we  desire  to  introduce  alimentary  sub- 
stances directly  into  the  stoftiaoh,  as  in  difficulties  of  deglu- 
tition, such  as  occur  after  resection  of  the  upper  or  lower 
jaw,  in  acute  tonsillary  angina  aad  in  rapidly  growing  pha- 
ryngeal abscesses.  It  is  also  required  in  the  insane  who 
refuse  to  take  food.  When  these  patients  will  not  open 
their  mouths,  the  oesophageal  catheter  is  either  introduced 
through  the  nose  or  the  patient  is  chloroformed  and  the 
tube  inserted  through  his  mouth.  To  avoid  inserting  the 
oesophageal  catheter  into  the  trachea,  which  would  be  fol- 
lowed by  the  introduction  of  alimentary  liquids  into  the 
respiratory  tract,  the  patient  is  narcotized  and  a  gag  placed 
between  his  teeth.  Then  the  patient  is  allowed  to  recover 
from  the  narcosis  and  the  thickest  oesophageal  sound  is  in- 
serted through  the  orifice  in  the  gag  down  to  the  stomach 
(Roser.)  The  larger  the  sound  selected,  the  safer  is  the 
avoidance  of  inserting  it  into  the  trachea.  Previous  to 
pouring  in  alimentary  liquids  a  few  drops  of  water  are  al- 
lowed to  run  into  the  catheter,  which  will  certainly  produce 
reflex  coughing  in  case  the  sound  has  been  inserted  into  the 
trachea. 

The  introduction  of  the  oesophageal  sound  is  most  easily 


SURGICAL  EMERGENCIES.  103 

done  when  the  patient  is  sitting,  His  head  is  held  as  far 
back  as  possible,  causing  the  free  edge  of  the  upper  incisor 
teeth  to  form  a  tangent  to  a  line  projected  from  the  axis  of 
the  oesophagus  (Trendelenburg).*  The  index  finger  of 
the  left  hand — which,  when  the  patient  is  a  child  or  insane, 
should  be  protected  with  a  metal  case — is  laid  upon  the 
tongue  as  far  as  the  epiglottis.  The  tongue  is  pressed 
downwards  and  the  catheter  is  inserted  over  it  to  the 
posterior  wall  of  the  fauces.  As  in  catheterizing  the 
urethra  the  symphysis  is  the  key  to  guide  the  instrument 
out  of  the  membranous  portion  into  the  neck  of  the 
bladder,  so  in  the  introduction  of  oesophageal  catheters  or 
bougies,  the  anterior  surface  of  the  spinal  column  against  which 
the  posterior  faucial  wall  lies,  is  the  guide.  If  the  patient  is 
caused  to  swallow  when  the  instrument  passes  the  entrance 
of  the  trachea,  and  thus  elevate  the  trachea,  and  close  the 
epiglottis  over  it,  the  entrance  of  the  instrument  into  the 
air-passages  is  more  surely  avoided. 

When  great  restlessness  or  excessive  sensibility  compels 
us  to  catheterize  the  oesophagus  in  the  narcotic  state, 
Girard's  f  process  is  recommendable.  It  consists  in  narco- 
tizing the  patient  in  the  horizontal  position  and  to  have 
his  head  fixed  by  an  assistant,  as  it  hangs  over  the  edge  of 
the  table  so  as  to  cause  the  margin  of  the  upper  incisors  to 
form  a  tangent  to  the  longitudinal  axis  of  the  oesophagus. 
The  operator  stands  at  the  left  shoulder  of  the  patient  and 
can  guide  the  straight  instrument  horizontally  into  the 
oesophagus  while  holding  it  in  his  "supine  hand  and  em- 
ploying delicate  tact.  Many  advantages  may  be  claimed 
for  Girard's  method  in  dilating  strictures  with  bougies,  the 
removal  of  foreign  bodies,  and  for  endoscopic  examination 
of  the  oesophagus  and  the  interior  of  the  stomach. 

We  shall  now  proceed  to  the  consideration  of  those  im- 
pediments which  may  disturb  the  progress  of  the  intestinal 
contents  within  the  small  and  large  intestine.  The  principal 
matter  with  which  we  have  to  deal  is  strangulated  hernia. 

As  you  know,  gentleman,  we  distinguish  reducible,  or 
mobile,  adherent  and  incarcerated  hernias,  and  under  ther- 

*  Treudelenburg,  Zur  Extraction  v.  Fremdkorpern  aus  dem  CEsopha- 
gus.  v.  Langenbeck's  Archiv,  1872,  Bd.  xiv.  p.  63. 

f  Girard,  Zur  Anwendung  d.  Narkose  b.  Untersuchungen  d.  Oesopha- 
gus, Centralbl.  f.  Chirurg.,  1880,  No.  21,  p.  337. 


104  SURGICAL  EMERGENCIES. 

apeutic  measures  we  discuss  reposition,  retention,  and 
radical  cure.  The  treatment  of  incarcerated  hernias  per- 
tains to  the  domain  of  urgent  life-saving  operation. 

You,  furthermore,  know  that  in  hernia  we  must  consider: 
i.  The  orifice  of  the  hernial  sac,  through  which  the  hernial 
tumor  escapes.  These  orifices  are  either  dilated  normal 
openings  in  the  abdominal  walls  (crural  rings,  inguinal 
canal,  umbilicus),  or  abnormal  slits  in  any  of  the  ventral 
walls  (diaphragmatic,  ventral,  perineal  hernias),  or  abnor- 
mal slits  brought  about  by  folding,  bending  or  twisting  of 
the  mesentery  and  the  intestines  themselves.  In  this  sense 
intussusception  and  ileus  belong  in  this  category. 

2.  As  to  the  hernial  contents.  All  of  the  abdominal  organs 
may  be  found  in  a  hernia.  However,  most  frequent  are 
hernias  of  the  gut  or  peritoneum  (enterocele  and  epiplo- 
cele)  or  both  together. 

3.  You  know  that  by  hernial  sac  we  mean  a  procidentia  of 
the  peritoneum  generally  involving  the  contents  of  the 
hernia. 

The  peritoneal  covering  may  be  absent,  (a)  in  vesical  her- 
nias, when  the  bladder  proceeds  directly  out  of  Retzius's 
prevesical  space  through  the  subcutaneous  inguinal  ring,  or 
(o)  when  the  ccecum,  the  posterior  side  of  which  is  not 
covered  by  peritoneum,  forms  the  contents  of  the  hernia. 
Finally  (c),  in  many  umbilical  hernias,  perhaps  because  of 
atrophy  of  the  peritoneal  pocket,  and  (d)  in  hernias  of  the 
umbilical  cord.  The  absence  of  peritoneal  covering  can 
furthermore  depend  on  a  rupture  of  the  hernial  sac,  or  an 
escape  of  the  ventral  contents  beneath  the  skin,  after  sub- 
cutaneous tearing  of  the  abdominal  walls. 

The  hernial  neck  is  especially  important;  it  is  created  by 
coalescence  of  the  folds  of  the  hernial  sac,  which  have  been 
formed  in  the  hernial  opening.  It  can  also  be  pushed  up- 
wards or  downwards  from  the  hernial. opening.  If  the  neck 
of  the  hernia  be  obliterated  after  replacing  or  reducing  the 
hernia,  a  hernial  cyst  may  form  (probably  certain  femoral 
cysts  below  Poupart's  ligament  may  be  considered  as  per- 
taining to  this  class). 

Hernias  which  are  not  invaginated,  may  be  irreducible 
either  because  of  the  large  mass  of  intestine — large  scrotal, 
umbilical,  or  ventral  hernias, — or  through  adhesion  of  the 
hernial  contents  with  the  sac,  or  neighboring  organs,  for 
instance,  within  the  scrotum,  as  in  congenital  inguinal 
hernial. 


SURGICAL   EMERGENCIES.  105 

Both  of  these  causes  for  the  irreducibility  of  hernias  may 
often  be  set  aside  by  continuous  efforts  at  taxis  (Arnaud, 
Hey,  Malgaigne),  for  five  or  six  weeks,  sometimes  success 
results  within  eight  to  fourteen  days,  during  which  com- 
pression with  lead  plates,  or  with  elastic  bandages,  has 
been  employed  during  the  intervals  between  each  seance. 
Irreducible  large  hernias  have  become  reducible  spontane- 
ously after  emaciation  following  acute  diseases. 

The  third  cause  for  the  irreducibility  is  found  in  incar- 
ceration.    We  observe  four  elements  to  it: 

1.  Inflammatory  swellings  of  the  surroundings  of  the  her- 
nial opening,  or  within  it  near  the  rupture — inflammation  in 
the  region  of  the  spermatic  cord  in  external  inguinal 
hernia.     It  is  very  rare. 

2.  Fcecal  filling  of  the  hernial  contents  :  incarceratio 
stercoralis — Engouement. 

3.  The  occurrence  of  a  sudden  disproportion  between  the 
hernial  contents  and  the  neck,  especially  when  the  latter 
has  been  subject  to  fibrous  thickening  by  prolonged  wear- 
ing of  a  truss,  and  the  intestinal  loop  has  been  forced  into 
the  hernial  sac  which  formerly  was  empty,  then  real  strang- 
ulation occurs.  The  disproportion  between  the  intestine 
and  the  hernial  neck — in  these  cases  the  intestinal  loop  is  often 
found  quite  empty, — is  caused  by  continued  increase  in  volume 
of  the  hernial  loop  in  consequence  of  circulatory  disturbances 
in  the  intestinal  walls.  These  are  most  frequently  of  a 
venous  character.  The  disturbances  maybe  quite  insignifi- 
cant in  the  beginning  (Borgreve's  experiments).  An  ex- 
ample thereof  might  be  made  of  a  metal  ring  which  can  be 
pushed  on  the  finger  easily;  but  soon  cedematous  swelling 
of  the  finger  takes  place  and  the  removal  of  the  ring  is 
rendered  difficult,  often  entirely  impossible. 

4.  Fibrous  bands  in  the  lumen  of  the  hernial  sac,  in 
which  the  intestinal  loop  may  be  doubled  upon  itself,  or 
wedged  in. 

The  dangers  of  invagination  are  in  proportion  to  its  de- 
gree and  rapidity  of  the  damming  of  the  circulation  in 
the  intestinal  loop.  When  circulation  is  suddenly  and 
totally  interrupted,  as  in  compression  of  the  veins  and 
arteries,  the  intestinal  loop  collapses,  becomes  anaemic, 
discolored,  gangrenous  (anaemic  gangrene,  Roser,*).  In 
such  cases  efforts  at  taxis  will  be   found  useless,  and  only 

*  Roser,  Centralbl.  f.  Chir.,  1879,  No.  40. 


106  SURGICAL  EMERGENCIES. 

rapid  operative  measures  will  save  the  loop  from  death. 
Relieving  invagination  in  these  cases  has  quite  justly  been 
compared  to  cutting  the  rope  in  hanging. 

The  symptoms  of  acute  invagination  are  very  violent.  In- 
tense pains  are  felt  while  the  swelling  in  the  region  of  the 
hernial  tumor  is  not  great.  The  hernial  tumor  may  soon 
show  a  doughy,  emphysematous  consistence,  caused  by  a 
development  of  gas  in  it. 

The  less  violent  course  of  invagination,  which  we  will 
designate  as  the  subacute  form,  is  found  in  such  cases  where 
the  impediments  to  circulation  are  produced  more  slowly. 
The  veins  as  they  lie  more  superficially  are  compressed 
first.  Therefore,  co-incident  with  circumscribed  venous 
stasis  an  increasing  oedema  of  the  intestinal  loop  presents 
itself,  then  transudation  into  the  hernial  sac  and  as  a  con- 
sequence of  the  stasis  extrusion  of  red  blood-corpuscles  into 
the  tissues  of  the  intestinal  walls,  all  producing  real  capillary 
and  larger  extravasations  of  blood.  In  these  cases  the  loop 
does  not  appear  steel-blue  or  grayish,  as  in  the  previous 
class,  but  dark  red  in  the  beginning,  and  later  brownish- 
red.  Inasmuch  as  the  arterial  supply  is  not  entirely  inter- 
rupted, despite  the  venous  stasis  the  danger  of  gan- 
grene is  not  so  great  and  often  is  delayed  for  several 
days.  Therefore  in  these  cases  taxis  promises  better  results. 

The  processes  which  we  have  designated  as  character- 
istic of  invagination  cannot  be  presented  schematically  bet- 
ter than  by  Cohnheim's*  original  experiments  on  tempo- 
rary interruptions  of  the  venous  and  arterial  circulations  in 
the  frog's  tongue.  Microscopic  observations  of  the  occur- 
rences which  take  place  in  the  tissues  of  the  tongue  are  so 
significant  that  if  you  wish  to  inform  yourselves  upon  the 
changes  which  a  hernial  loop  suffers  on  invagination,  I  can- 
not too  urgently  recommend  you  to  a  study  of  the  above 
experiments. 

In  general,  the  symptoms  will  be  more  violent  the  more 
acute  the  strangulation,  as  is  shown  by  the  intensity  of  the 
pains  and  general  collapse.  Stercoraceous  vomiting  is  of- 
ten absent  in  a  rapid  course  of  the  affection  but  in  general  it 
presents  itself  the  sooner,  the  nearer  the  invaginated  intes- 
tinal loop  is  to  the  stomach. 

Real    strangulations    must  be    distinguished  from    ap- 

*  Cohnheim,  Neue  Untersuchungen  iiber  d.  Entziindungen,  Berlin, 
J873,  and  Vorlesungen  ii.  allgem.  Pathologie,  Bd.  i.,  pp.  108  to  133, 


SURGICAL   EMERGENCIES.  10? 

parent  ones,  that  is,  those  in  which  the  series  of  symptoms 
which  resemble  those  of  strangulation  are  dependent  upon 
other  causes. 

Thus  we  find  (a)  peritonitis  within  the  hernial  sac.  It  may 
occur  after  traumatism  to  any  empty  hernial  sac.  Or  they 
may  be  developed  when  the  projecting  intestinal  loop  suffers 
perforations  of  its  wall  by  foreign  bodies  or  ulcerations. 
Furthermore  (b)  in  this  connection  must  be  considered  in- 
flammation of  a  serous  membrane  adherent  within  the  hernial  sac 
(so-called  inflammatory  invagination);  and  then  (c)  spasmodic 
invagination.  This  refers  to  spasmodic  anti-peristaltic  motion 
of  intestinal  loops  in  atony  of  the  intestine,  or  may  depend 
upon  tension  on  the  mesentery  in  large  adherent  ruptures. 
Finally,  we  will  mention  (d)  intussusception,  which  may  oc- 
cur within  the  abdomen,  as  also  within  a  hernia. 

Omitting  the  treatment  of  apparent  strangulation,  we 
would  employ  antiphlogistic  means  in  peritonitis  of  the  her- 
nial sac  as  well  as  in  inflammatory  epiplocele  accreta.  When 
an  abscess  forms,  especially  in  intra-hernial  peritonitis,  open- 
ing the  abscess  becomes  necessary.  In  intestinal  colics  we 
wouki  have  to  employ  the  wet  pack,  clysters  of  opium  and  pur- 
gatives. In  intussusception  laparotomy  may  be  thought  of 
in  case  the  intussusception  occurs  within  the  abdomen.  But 
if  symptoms  of  intussusception  are  accompanied  by  perito- 
nitis in  the  hernial  sac,  we  will  have  to  proceed  to  an  explor- 
atory herniotomy.  This  applies  to  cases  where  the  symp- 
toms of  strangulation  occur  with  multiple  irreducible  her- 
nias. 

Before  we  proceed  to  the  treatment  of  hernial  strangula- 
tion we  will  first  call  to  our  minds  the  place  or  site  where 
it  may  occur.  In  recent  hernias  the  hernial  opening  itself 
may  be  the  contracting  point,  and  this  opening  may  appear 
as  a  ring  (crural  ring),  or  as  a  canal  (inguinal  canal),  or  as  a 
split  in  the  abdominal  coverings.  In  old  hernias,  especially 
where  a  truss  has  been  worn  for  a  long  time,  the  seat  of  the 
strangulation  generally  takes  place  in  the  fibrous  thickened 
neck  of  the  sac,  which,  as  we  have  seen,  may  sometimes  be 
above  and  sometimes  below  the  hernial  opening.  Thirdly, 
the  strangulation  may  occur  neither  through  the  hernial 
opening  nor  the  neck,  but  through  neoplastic  bands  with- 
in the  hernial  sac  itself,  or  produced  by  an  intestinal  loop 
being  caught  in  an  opening  of  the  peritoneal  net.  The  net 
also,  in  an  epiplocele,  when  it  has  been  converted  into  a 
pear-shaped  polypoid    tumor,  may  produce   strangulation 


108  SURGICAL   EMERGENCIES. 

when  it  is  withdrawn  towards  the  hernial  opening.  As  it 
becomes  wedged  in  there,  it  presses  upon  the  gut  between 
itself  and  the  hernial  opening. 

The  treatment  of  strangulated  hernia  implies  the  essential 
principles  that  are  suggested  by  acute  interruptions  of  cir- 
culation in  the  intestine  in  recent  ruptures  with  violent 
pains,  rapid  collapse,  etc.,  (strangulated  loop).  The  only  life 
saving  means  is  herniotomy  executed  as  soon  as  possible.  In  less 
acute  strangulations  the  mechanism  is  to  be  considered,  and 
taxis  first  employed. 

Three  manipulations  are  to  be  distinguished  in  taxis,  ac- 
cording to  the  mechanism  of  the  strangulation.  In  case 
taxis  does  not  succeed  immediately,  the  success  may  be  at- 
tained in  repeating  the  manipulations  under  the  influence  of 
an  anaesthetic: 

(a)  The  mechanism,  according  to  Lossen,*  applies  especially 
to  fcecal  impaction  and  is  brought  about  in  the  manner  that 
I  will  show  you.  If  a  loop  of  intestine  be  made  to  traverse  a 
hole  bored  through  a  plank,  which  hole  is  somewhat  smaller 
in  diameter  than  the  part  of  the  loop  which  enters  it  and 
if  you  force  into  the  intestine  any  substance  which  in  con- 
sistence resembles  the  fcecal  mass  (as  boiled  peas  or  grits) 
a  moment  will  arrive  when  the  mass  can  no  more  be  forced 
into  the  part  of  the  loop  below  the  opening  in  the  board. 
Close  examination  will  show  you  that  the  lumen  of  the  affer- 
ent loop  within  the  artificial  hernial  rupture  is  completely 
choked  and  pressed  against  the  wall,  while  the  lumen  of 
the  efferent  part  is  filled  entirely  with  the  above-named 
pap.  The  mechanism,  according  to  Lossen,  consists  of  the 
sudden  filling  of  the  afferent  part  of  the  intestine  with 
tough  matters  which  it  is  difficult  to  move,  so  that  the  ring 
of  the  hernial  opening  is  completely  occupied  by  it  and 
the  walls  of  the  efferent  part  of  the  gut  are  so  pressed  to- 
gether that  the  progress  of  its  contents  is  prevented.  If  we 
reduce  the  diameter  of  the  afferent  part  of  the  intestine 
within  the  hernial  opening  then  the  intestinal  contents 
can  extend  the    efferent   part   and    thus  make  their   way 

*  Lossen,  Studien  u.  Experimente  u.  d.  Mechanismus  d.  Bruchein- 
klemmung,  Verhandl.  d.  iii.  Congress,  d.  Deutsch.  Gesellsch.  f.  Chirurg., 
1874,  and  v.  Langenbeck's  Archiv.  B.  xvii.,  p.  301.  Compare  excellent 
articles  by  Busch,  Lossen,  Roser  in  Centralblatt  f.  Chir.,  1874.  and  by 
Bidder,  Kocher,  Lossen,  and  Roser  in  same  journal  1875,  as  well  as 
Grossere  Vortrage,  by  Busch,  Lossen,  and  Roser  in  the  Verhandl.  d, 
iv.  Congr.  d.  Deutsch.  Gesellsch.  fr.  Chir.  im  Jahre,  1875. 


SURGICAL   EMERGENCIES.  109 

out  of  it.  To  bring  about  the  same  results  in  a  real  her- 
nia with  faecal  impaction,  we  must  exercise  pressure 
upon  the  afferent  intestine  within  the  hernial  opening.  This 
pressure  must  be  made  radially,  from  the  side  of  the  choked 
afferent  intestine  to  the  opposite  point  of  the  circle  of  the 
hernial  opening.  Inasmuch  as  we  cannot  tell  at  what  place 
the  afferent  gut  is  compressed  during  life,  therefore  we  will 
have  to  compress  the  afferent  gut  within  the  hernial  open- 
ing towards  all  sides  radially,  until  the  pressure  upon  the 
tensely  filled  hernial  tumor  produces  free  motion  of  its  con- 
tents and  thus  relieves  the  faecal  impaction. 

According  to  Roser,*  the  impaction  is  brought  about  by 
a  lack  of  proportion  between  the  loop  and  the  neck  of  the 
hernia,  which  results  in  the  formation  of  longitudinal  folds 
in  the  intestinal  walls,  within  the  hernial  neck,  whereby  a 
flap  like  mechanism  is  produced  which  when  the  base  of  the 
hernial  tumor  is  pressed  upon  causes  complete  shutting  off 
of  the  intestinal  contents  from  the  intestinal  tube  above  the 
hernial  neck.  In  order  that  reduction  may  succeed,  simp1e 
pressure  from  the  base  of  the  hernial  tumor  in  the  direction 
of  the  hernial  opening  must  not  be  exercised,  as  thereby 
the  form  of  the  tumor  will  be  converted  from  that  of  a 
pear-shaped  long-necked  bottle  into  that  of  a  flask  which 
has  been  flattened  in  its  longitudinal  axis.  But  we  must 
compress  the  hernial  tumor  with  the  fingers  of  one  hand 
closely  beneath  the  hernial  opening,  while  we  grasp  the  tu- 
mor with  the  other  hand  and  endeavor  to  conduct  its  elon- 
gated form  back  through  the  neck  of  the  hernial  tumor 
(Streubel  f). 

(c)  BuschJ  holds  that  we  must  picture  impaction  of  an 
intestinal  loop  thus:  repletion  of  the  intestine  extends  its 
free  outer  wall,  more  than  its  inner  one,  and  the  mesentery 
becomes  adherent,  thus  a  doubling  of  the  afferent  as  well  as 
efferent  gut  is  produced  within  the  hernial  orifice,  prevent- 
ing further  passage  of  the  intestinal  contents  to  the  intes- 
tine beyond  the  hernial  tumor.  The  passage  is  only  made 
possible  by  relieving  the  doubling  within  the  hernial  orifice 
in  bending  the  hernial  tumor  in  the  opposite  direction,  thus 


*  Roser,  Archiv.  f.  physiol.,  Heilkunde  1856,  1857,  i860  and  1864. 
Compare  also  Roser's  Handb.  der  Anat.,  Chir.,  1872,  p.  343. 

f  Streubel,  Prager  Vierteljahrschr.,  1861,  Bd.  1,  p.  I. 

\  Busch,  Sitzungsberichte  d.  Niederrhein.  arztl.  Gesellschr.  v.  10, 
Marz.,  1863. 


IIO  SURGICAL  EMERGENCIES. 

straightening  the  axes  of  both  the  efferent  and  the  afferent 
intestines. 

Besides  narcosis,  certain  positions  of  the  lower  extremi- 
ties facilitate  taxis;  flexion  and  adduction  of  the  thighs  relax 
the  abdominal  walls  and  reduce  the  tension  of  the  inguinal 
canal.  In  crural  hernias  coincident  rotation  of  the  thighs 
inwards  favors  a  relaxation  of  the  fascia  lata.  Elevation  of 
the  coccyx  acts  by  allowing  the  intestines  to  fall  back  against 
the  diaphragm  and  by  the  traction  which  the  mesentery  is 
thus  caused  to  make  upon  the  hernial  loop.  In  like  man- 
ner deep  inspirations,  lying  on  the  healthy  side  and  perhaps 
also  a  knee-elbow  position,  exert  their  influence.  Those  adju- 
vants to  taxis  which  were  formerly  recommended,  as,  bleed- 
ing, leeches,  the  warm  bath,  extensive  cupping  of  the  abdo- 
men, warm  fomentations,  narcotics,  (opium,  belladonna)  etc., 
have  been  entirely  substituted  by  chloroform  (or  ether)  nar- 
cosis. The  administration  of  purges,  clysters,  tobacco  (inf. 
fol.  nicot.  [5.0]  200,0;  gummi  mimos,  10,0  ol.  ricini  15,  o; 
M.  D.  S.  for  two  injections)  the  ice  bag,  direct  compression 
of  the  hernial  tumor  (elastic  compress),  have  yielded  favora- 
ble results  only  in  isolated  cases,  and  then  owing  to  particu- 
larly favorable  circumstances.  Results  should  sooner  be 
expected  from  forcible  injection  or  pouring  of  water  into 
the  rectum,  as  in  ileus. 

When  taxis  is  properly  made  under  the  influence  of  an  an- 
aesthetic we  will  not  hesitate  to  proceed  immediately  to  herni- 
otomy, utilizing  the  existing  narcosis  and  having  made  all 
preparations  before.  We  will  now  occupy  our  attention  with 
the  details  of  this  operation. 

1.  We  must  consider  the  cases  wherein  apparently  suc- 
cessful taxis  makes  herniotomy  become  necessary.  Spuri- 
ous reduction,  apparent  reduction,  false  reduction  (Streu- 
bel*)  occurs  upon  returning  the  hernial  loop  en  bloc  with  its 
sack  in  strangulation,  above  the  hernial  orifice  between  the 
abdominal  parietes  and  the  peritoneum  parietale.  A  simi- 
lar occurrence  can  take  place  after  opening  the  hernial  sack 
in  herniotomy  when  the  hernial  walls  are  not  fixed  during 
reposition  of  the  loop.  Then  the  gut  may  be  forced  through 
the  dilated  hernial  neck  into  the  abdominal  cavity  beside 
the  neck,  and  between  the  peritoneum  and  abdominal  wall. 

2.  By  annular  tearing  of  the  constringent  hernial  neck, 


*  Streubel,  Ueber  d.  Scheinreductionen  b.  TIernien,  Leipzig,  1864. 


SURGICAL  EMERGENCIES.  Ill 

which  is  pushed  into  the  abdominal  cavity  with  the  hernial 
tumor. 

3.  By  returning  the  prolapsed  intestinal  loop  without  re- 
lieving its  torsion  or  invagination. 

Herniotomy,  the  operation  for  relief  of  intestinal  strangu- 
lation, has  saved  more  human  lives  than  have  all  other 
means  which  have  been  recommended  or  adopted  for  their 
relief;  notwithstanding  that  the  proximity  of  the  abdominal 
cavity  made  this  measure  always  appear  one  which  required 
serious  consideration,  previous  to  the  period  of  the  antisep- 
tic treatment  of  wounds. 

Herniotomy,  as  well  as  lithotomy,  is  said  to  have  been  first 
recommended  in  the  middle  of  the  sixteenth  century  (Fran- 
co*); Ambroise  Pare  f  often  performed  it  successfully. 
Special  instruments  are  not  at  all  requisite  for  this  opera- 
tion; the  necessary  instruments  are  found  in  every  operat- 
ing case. 

The  strangulated  loop  is  exposed  by  splitting  the  soft  parts 
which  lie  upon  it  according  to  the  rules  which  were  learned 
for  isolating  the  larger  vessels  and  for  opening  the  trachea. 

We  first  incise  the  skin  in  the  direction  of  the  long  diame- 
ter of  the  hernial  tumor.  In  femoral  hernia  this  would 
imply  an  incision  parallel  to  the  axis  of  the  femur,  while 
inguinal  hernias  require  an  incision  parallel  to  Poupart's 
ligament  which  will  have  to  extend  to  the  scrotum  in  the 
male  or  the  labium  maj.  in  the  female.  An  exception  there- 
to is  made  in  strangulated  umbilical  hernias,  which  preclude 
opening  the  hernial  tumor  at  its  apex,  because  of  the  thin- 
ness of  its  coverings.  According  to  the  maxims  which  have 
been  already  enunciated,  an  incision  is  made  either  in  the 
linea  alba  or  in  a  direct  parallel  to  the  base  of  the  hernia 
and  near  it  (preferably  to  the  left).  Then  the  umbilical 
ring  is  freed  and  notched,  as  is  the  hernial  neck  within  it, 
so  as  to  permit  the  extraction  of  the  intestinal  loop  from 
the  hernial  sack  after  separation  of  its  adhesions.  The  other 
hand  supports  the  region  by  compression  of  the  hernial 
tumor  from  without  (Dieffenbach I).  The  further  treatment 
of  the  wound  is  similar  to  that  of  laparotomy. 

In  all  other  stranglated  hernias  after  splitting  the  skin, 
the  sub-adjacent  tissues  must  be  separated  with  a  knife  for 

*  franco,  Traite  des  hernies,  Lyon,  1561. 

j  Ambroise  Pare,  CEuvres  completes;  ed.  Malga.  -ne,  Paris,  1840. 

\  Dieffenbach,  Operative  Chirurgie.     Bd.  ii.,  p.  oil 


112  SURGICAL  EMERGENCIES. 

which  purpose  they  are  elevated  singly  with  two  rat-toothed 
forceps  as  thin  plates  of  connective  tissue.  Formerly  it  was 
customary  to  drill  the  several  connective  tissue  layers  apart 
with  a  hollow  sound,  but  this  practice  is  decidedly  repre- 
hensible. 

The  impediments  to  circulation  in  the  hernial  loop  are  fol- 
lowed by  the  transudation  of  a  fluid  into  the  sack  (Bruchwas- 
ser).  The  escape  of  this  fluid  is  the  most  reliable  sign  in  many 
cases  that  we  have  opened  the  hernial  sack.  But  in  oedema  of 
the  hernial  sack-walls,  fluids  may  also  be  found  between  the 
separated  layers.  Again,  it  may  happen  that  there  is  no  her- 
nial fluid  (Bruchwasser)  which  occurs  especially  in  crural 
hernias  and  markedly  so  in  very  acute  strangulations  or  also 
in  cases  which  progress  very  slowly  (hernia  sicca).  In  the 
latter  cases  adhesions  are  often  found  between  the  intesti- 
nal loop  and  the  hernial  sack.  Then  great  care  is  required  in 
our  procedures,  lest  the  gut  be  split. 

In  former  times  the  question  was  discussed  whether  her- 
nias could  be  relieved,  especially  in  cases  of  recent  strangu- 
lation, without  opening  the  hernial  sack  (external  herni- 
otomy.) It  was  proposed  to  free  the  hernia  with  its  sack 
from  the  site  of  contraction  by  incision,  tearing  or  separa- 
tion with  the  fingers.  This  procedure  does  not  appear  reli- 
able; as,  first,  the  strangulation  happens  frequently  within 
the  hernial  sack  and  then,  above  all,  the  method  allows  no 
view  of  the  intestine.  The  other  advantages  which  are 
claimed  for  external  herniotomy  have  lost  weight  since  the 
introduction  of  antisepsis. 

Therefore  it  is  more  advantageous  to  free  the  intestinal 
loop  by  opening  the  hernial  sac  and  relieving  the  strangulation 
directly  (internal  herniotomy).  For  this  purpose  a  probe- 
pointed  somewhat  curved  knife,  with  a  concave  cutting  edge, 
like  a  bistoury  of  the  ordinary  pocket-case,  is  used.  Special 
herniotomes  are  mentioned  and  called  after  known  sur- 
geons (Pott,  A.  Cooper,  Rust,  Seiler,  and  Tesse.  The 
knives  of  the  latter  have  convex  cutting  edges.  Grzymala 
has  devised  a  cover  for  the  point  of  a  convex  knife.) 

To  enlarge  the  site  of  constriction  the  knife  must  not  be 
drawn,  but  allowed  to  act  by  pressure.  It  is  introduced  into 
the  contracted  site,  lying  flatly  upon  the  index  finger,  the 
cutting  edge  is  then  erected  against  the  constricting  ring, 
and  by  pressure  of  the  finger  upon  the  blade  it  is  made  to 
notch  the  ring  at  various  places  in  a  centrifugal  direction 
(Vidal's  debridement  multiple).    For  this  purpose  the  her- 


SURGICAL  EMERGENCIES.  113 

niotome  need  be  sharp  at  its  free  end  only  as  is  Cooper's 
bistoury,  which  may  be  improvised  by  wrapping  the  greater 
part  of  the  blade  of  a  Pott's  knife  with  adhesive  plaster. 
Multiple-notching  for  the  relief  of  the  constriction  is  highly 
advantageous  over  unilateral  incision  (Pott,  Garangcot), 
which  requires  special  care  in  inguinal  hernias  to  avoid 
wounding  the  epigastric  artery.  If  Gimbernat's  ligament 
were  split  towards  the  symphysis  there  would  be  danger  of 
wounding  the  obturator  artery  in  case  the  latter  should 
take  an  abnormal  course  from  the  epigastric  around  the 
crural  ring  descending  to  the  obturator  foramen  (Todten- 
ring,  death-ring).  But  the  possibility  of  wounding  this 
artery  has  been  very  much  exaggerated,  and  has  detained 
many  from  performing  herniotomy.  Thus  Dieffenbach  is 
perfectly  right  in  saying  that  the  fear  of  wounding  an  ab- 
normal epigastric  artery  has  cost  more  human  lives  than 
the  injury  itself  (Operat.  Chirurgie,  Band  II.,  p.  480.) 

The  second  step  of  herniotomy,  the  multiple-notching  of 
the  contracted  part  of  the  hernial  opening  or  sack,  frees 
the  contents  of  the  hernia  from  constriction.  And  now  the 
third  step,  the  reposition  of  the  hernial  contents  will  be  con- 
sidered. 

The  freed  intestinal  loop  should  never  be  returned  to  the 
abdominal  cavity  without  first  drawing  it  forth,  to  assure 
us  that  there  is  no  further  site  of  contraction  higher  up  in 
the  hernial  sack.  Secondly,  we  must  assure  ourselves  of  the 
condition  of  the  loop,  especially  at  those  places  which  have 
been  subject  to  direct  constriction,  and  which  have  often 
been  left  with  gangrenous  marks  as  the  result  of  pressure. 
If  the  loop  is  quite  healthy,  such  adhesions  as  may  exist 
should  be  broken  up,  and  then  the  loop  returned  in  such  a 
manner  that  that  part  of  the  intestine  which  prolapsed  last  is  re- 
turned first.  Old  adhesions  which  are  separable  with  diffi- 
culty, or  not  at  all,  notwithstanding  the  relief  from  con- 
striction, will  oblige  us  to  return  the  intestine  in  the  old 
position.  If  the  appearance  of  the  loop  is  not  normal,  all 
those  manifestations  which  we  have  described  in  sudden  or 
slow  interruptions  of  the  venous  and  arterial  circulation  in 
the  intestinal  canal,  must  be  considered  in  the  interests  of 
prognosis.  Then  Cohnheim's  experiments  on  the  tongue 
may  serve  as  examples.  It  will  be  especially  difficult  to  de- 
cide whether  a  discolored  spot  in  the  intestinal  walls  will 
return  to  a  normal  condition  or  will  suffer  mortification. 
In  this  sense  many  fatal  errors  have  been  committed. 


114  SURGICAL  EMERGENCIES. 

If  a  part  of  the  intestine  is  really  gangrenous,  or  if  a  per- 
foration has  occurred,  our  subsequent  treatment  has  a 
more  distinct  base.  In  round,  hole-shaped  perforations  it 
has  been  proposed  to  draw  forth  the  affected  part  of  the  in- 
testine with  a  forceps,  and  to  place  a  ligature  about  the 
base  of  the  cone  thus  drawn  forth,  just  as  Cooper  proposed 
in  hole-shaped  injuries  to  the  larger  venous  branches. 
Linear  necroses  of  the  intestinal  wall  are  most  frequently 
diagonal  to  and  sometimes  at  an  angle  to  the  intestinal 
canal,  and  corresponding  to  the  contracting  ring.  In  such 
cases  the  dead  parts  may  be  excised  and  the  lips  of  the 
wound  drawn  together  by  button-sutures  or  by  continuous 
suture  in  such  a  manner  that  the  serous  surface  of  the  lips 
of  the  wound  are  brought  in  exact  opposition,  and  the  mu- 
cous margins  are  turned  over  to  project  into  the  intestinal 
lumen  (Lembert's  suture). 

The  same  principles  guide  our  application  of  sutures 
when  an  entire  loop  of  intestine  has  become  gangrenous, 
and  we  wish  to  unite  the  upper  stump  of  the  amputated 
gut  with  that  which  was  below  the  contraction.  The  safest 
course  in  these  cases  is  that  laid  down  by  Kocher's  excellent 
advice.  Beyond  all,  not  only  must  the  gangrenous  loop  be 
excised,  but  also  so  much  of  the  neighboring  part  of  the 
gut  as  may  appear  suspicious — that  is,  discolored  brownish 
or  blackish  red,  swollen,  or  covered  with  fragile  dim  serous 
membrane,  or  filled  with  mucus  of  a  bloody  tinge,  or,  in  a 
word,  so  much  must  be  removed  as  appears  infarcted.  The 
infarction  depends  on  a  venous  stasis  within  the  intestinal 
walls  that  have  been  tensely  stretched  in  the  strangulation. 
This  stretching  almost  always  affects  the  afferent  gut.  The 
resection  of  the  part  of  intestine  which  is  to  be  removed  is 
begun  by  notching  the  constricting  ring  as  much  as  possi- 
ble, so  as  to  be  able  to  draw  forth  the  intestine  easily. 
Large  clamps,  or,  in  emergencies,  temporary  ligatures,  are 
made  to  close  the  upper  and  lower  boundaries  of  the  dead 
parts.  These  should  be  applied  to  healthy  intestine.  At 
the  same  time  fixed  ligatures  are  made  to  secure  both  ends 
of  the  piece  of  intestine  which  is  to  be  excised,  and  a  strong 
silk  thread  is  tied  around  the  mesenteric  fold  which  per- 
tains to  the  necrotic  loop.  Then  the  scissors  are  used  to 
excise  the  necrotic  gut  between  two  ligatures,  or  between 

*  Kocher,  Zur  Methode  d.  Darmresection  b.  eingeklemmter  ga.ngrano- 
ser  Hernie.     Centralblatt  f.  Chir.,  1880,  No.  29. 


SURGICAL   EMERGENCIES.  1 1  5 

ligature  and  clamp,  taking  great  care  not  to  soil  any  of  the 
parts  with  the  contents  of  the  healthy  intestine,  nor  with 
gangrenous  bits,  and  particularly  to  avoid  the  entrance 
of  either  into  the  abdominal  cavity.  Finally,  the  excised 
piece  is  separated  from  its  mesentery,  which  has  been  li- 
gated. 

Then  threads  are  drawn  through  the  intestinal  stumps 
bevond  both  clamps,  which  threads  are  to  be  used  for  the 
application  of  Lembert's  suture.  The  stitches  are  ran 
through  the  intestinal  wall  parallel  to  its  serous  surface  in 
such  a  manner  that  they  do  not  penetrate  anywhere  into 
the  intestinal  lumen.  Previous  to  tying  the  sutures,  those 
parts  of  the  intestinal  stumps  which  have  been  clamped  or 
tied  are  cut  off  with  the  scissors,  between  the  clamp  and 
line  of  suture,  or  between  the  temporary  ligature  and 
line  of  suture.  It  is  also  recommendable  to  allow  the  con- 
tents of  the  upper  part  of  the  intestine,  which  are  mostly 
mixed  with  blood,  to  run  into  a  dish  previous  to  tying  the 
threads.  Besides  the  deep  sutures,  smaller  superficial  peri- 
toneal sutures,  which  grasp  only  serous  membrane,  must  be 
placed  between  them.  After  complete  disinfection,  the  in- 
testine which  has  been  restored,  by  suture,  is  to  be  re- 
turned. Tension  on  the  line  of  suture  is  best  avoided  on 
reposition,  as  has  been  mentioned,  by  thoroughly  notching 
the  contracted  site  of  the  hernial  sac.  In  all  cases  the 
double  suture  must  be  made  carefully  and  closely,  especially 
in  the  vicinity  of  the  mesenteric  insertion,  to  insure  that  the  in- 
testinal contents  will  nowhere  escape  between  the  stitches. 
Kocher  recommends  opium  in  the  after-treatment,  but 
attaches  more  importance  to  the  emptying  of  the  upper  in- 
testinal stump  previous  to  suture,  as  has  been  cited,  as  well 
as  subsequently  washing  out  the  stomach  with  borated 
water,  so  as  to  disencurnber  the  sewed  intestine  entirely. 
During  the  ten  days  following  the  patient  must  swallow 
nothing  but  smalTpieces  of  ice.  Nutrition  is  carried  on  by 
injections  into  the  rectum. 

Enteroraphy,  after  resection  of  a  gangrenous  gut,  is  the 
simplest  and  safest  procedure,  which  will  seldom  disap- 
point in  recent  cases,  when  skillfully  executed.  Resections 
of  the  gut,  followed  by  enteroraphy,  should  substitute  all 
other  measures  for  the  treatment  of  gangrenous  hernias.* 

*  It  has  been  shown  experimentally  that  long  intestinal  loops  can  be 
removed   from  their  continuity  of  the  intestinal  tube,  so   that  they  re- 


lid  SURGICAL  EMERGENCIES. 

When  the  greater  part  of  the  circumference  of  an  intestinal 
loop  is  necrosed  and  the  restoration  of  its  lumen  is  impos- 
sible, and  where  an  entire  resection  of  the  affected  intes- 
tinal piece  is  not  made,  the  necrotic  gut  has  occasionally 
been  simply  incised  and  fixed  in  the  wound  with  a  few 
stitches.  It  is  self-evident  that  this  operation  must  be  fol- 
lowed by  an  artificial  anus. 

If  it  be  decided  to  cure  this  subsequently  by  an  enter- 
oraphy,  other  conditions  than  those  incidental  to  a  primary 
resection  of  a  gangrenous  loop  prevail.  After  the  point  of 
attachment  of  both  intestinal  stumps  in  the  abdominal  wall 
has  been  split  or  circumcised  and.  the  intestinal  stumps 
separated  from  the  abdominal  fistula  and  their  margins  re- 
freshed diagonally,  the  upper  intestinal  end,  which  generally 
is  the  only  one  in  function,  appears  dilated,  while  the  lower 
one  is  callapsed  and  much  narrower  than  normally.  The 
dilatation  of  the  upper  intestinal  tube  which  terminates 
in  the  abdominal  fistula,  will  appear  greater  in  pro- 
portion to  the  amount  of  contraction  which  has  occurred 
in  the  mouth  of  the  fistula.  When  considerable  incon- 
gruity was  found  in  the  sizes  of  the  intestinal  stumps 
the  larger  intestine  which  was  folded  over,  or  an  edge 
thereof  was  placed  within  the  lumen  of  the  narrower,  which 
had  been  cut  through  diagonally,  and  then  Lembert's 
suture  applied,  as  usual,  after  the  tube  was  also  fastened 
by  sutures  within  the  smaller  intestine  (Billroth*,  Czerny). 
Or,  as  was  advised  by  Jobert,  the  wider  intestinal  tube  was 
folded  in  upon  itself  while  the  narrow  one  was  simply 
pushed  into  the  other  one.  Complicated  propositions,  such 
as  for  instance,  Denan's  suture  with  three  cylinders  pushed 
into  the  intestine,  are  worthless. 

The  principles  for  the  treatment  of  a  rupture  after  relief 
of  the  constriction,  are  somewhat  modified  when  the  rupture 
contains  peritoneum  only  or  peritoneum  and  intestine, 
normal  and  healthy  peritoneum  may  be  simply  replaced 
like  normal  gut.     Peritoneum  that  is  adherent  to  the  hernial 

main  connected  only  with  the  mesentery.  If  then  the  lumen  of  the  re- 
moved piece  is  thoroughly  washed  with  five-per-cent  carbolic-acid  solu- 
tion, the  piece  of  gut  with  its  two  open  ends  may  be  replaced  within  the 
ventral  walls  without  evil  consequences.  Of  course  the  two  intestinal 
stumps  must  be  brought  together  to  restore  the  continuity  of  the  intes- 
tine. 

*  Billroth,  Ueber  Enteroraphie.  Wiener  Med.  Wochenschrift,  1879, 
No.  1. 


Surgical  emergencies.  117 

orifice  is  soon  permeated  by  granulations,  and  finally  shrinks, 
while  it  often  yields  a  good  permanent  closure  of  the 
hernial  opening.  Parts  of  hypretrophic,  degenerated  peri- 
toneum which  have  become  converted  to  a  rolled-up  lump 
of  connective  tissue,  should  be  excised  after  the  stem  of  the 
epiplocele  has  been  ligated  en  masse  or  when  this  stem  is  ex- 
traordinarily thick,  after  its  vessels  have  been  provided  with 
ligatures.  Those  convulsive  and  inflammatory  manifesta- 
tions which  formerly  followed  this  ligature  en  masse 
(symptoms  of  strangulation,  vomiting,  and  sub-serous  phleg- 
mons) are  to  be  attributed  to  defective  treatment  of  the 
wound  and  not  as  a  consequence  of  traumatic  irritation 
by  the  ligature  en  masse. 

The  after-treatment  of  herniotomies,  in  which  antiseptic 
measures  have  been  strictly  followed,  after  reposition  of 
the  intestine,  the  wound  of  the  skin  may  be  sewed  sub- 
sequent to  the  insertion  of  a  drainage  tube  into  the  hernial 
sack.  It  appears  far  more  appropriate  after  reposition  of 
the  hernia,  to  isolate  the  neck  and  to  draw  it  up  as  high  as 
possible  against  the  abdomen  with  a  stout  thread  which 
has  been  boiled  in  a  five-per-cent  carbolic  solution  and  to 
remove  the  sack  in  toto  from  its  surroundings  below  the 
constriction.  This  method  of  radical  cure  of  hernia  which 
can  be  executed  in  most  of  those  which  have  been  strangu- 
lated and  reduced  by  operation,  has  been  resuscitated  re- 
cently under  the  protection  of  Lister's  treatment,  while  in 
the  past  it  had  been  known  and  practiced,  yet  desisted  from 
owing  to  its  dangers.  The  radical  treatment  of  hernias  in 
the  recent  antiseptic  period,  are  especially  discussed  in  the 
works  of  Czerny*,  Riself,  Schedef,  Maas§,  and  Steffen  ||. 

In  inguinal  hernias,  after  ligation  of  the  neck,  the  hernial 
opening  is  closed  with  special  sutures  (Czerny's  corset  su- 
tures or  also  the  mattress  suture).  The  cases  which  until 
now  have  been  operated  upon,  according  to  the  above 
method  with  antiseptic  precautions,  have  yielded  very 
favorable  results  as  regards  life.     The  rupture  itself  is  to 

*  Czerny.  Studien  zur  Radicalbehandlung  d.  Hernien.  Wiener  Med. 
Wochenschr.,  1887,  Nos.  21  to  24. 

+  Riesel,  Deutsche  Med.  Wochenschr.,  1877,  Nos.  38  and  39. 

I  Schede,  Centrabl.  f.  Chir.,  1877,  No.  44. 

§  Maas,  Ueber  Endresultate  radicaler  Hernienoperationen.  Breslauer 
arztl.  Zeitschr.,  1879.  Nos.  5  and  6. 

||  Steffen  (Socin's  Klinik),  Ueber  Radicaloperation  d.  Hernien.  Basel 
Franz.  Diss.  1879. 


IlS  SURGICAL  EMERGENCIES. 

be  considered  as  cured  in  many  cases  as  soon  as  the  pa- 
tients can  follow  a  part  of  their  occupations  without  a 
truss.  Partly,  at  least,  so  much  was  attained  that  ruptures 
which  previous  to  the  operation  could  not  be  contained  by 
a  truss,  permitted  one  to  be  worn  thereafter.  How  long 
this  condition  lasts,  whether  the  cure  remains  definite  or 
whether  relapses  would  notwithstanding  occur  upon  dis- 
carding the  truss,  are  questions  which  cannot  be  definitely 
answered  as  yet,  owing  to  the  brevity  of  time  which  has 
been  devoted  thus  far  to  these  operations. 

If  no  radical  cure  has  been  attempted,  the  patient  is  al- 
lowed to  rise  after  the  wound  is  healed  and  to  exchange  his 
antiseptic  compress-bandage  for  a  truss. 

But  when  a  gangrenous  rupture  has  been  treated,  where 
the  formation  of  an  artificial  anus  is  inevitable,  the  faeces 
will  cover  the  wound  permanently  and  prevent  its  antiseptic 
treatment.  Then  the  wound  must  be  simply  left  open  or 
covered  with  disinfecting  dressings  (carbolized  or  salicylated 
oil  compresses)  and  unimpeded  evacuation  of  the  excre- 
ments as  well  as  the  secretions  from  the  wound  must  be 
provided.  The  subsequent  relief  for  unnatural  anus  has 
been  briefly  discussed  above. 


SURGICAL  EMERGENCIES.  119 


LECTURE  IX. 

Gastrotomy. — Indications . — History. — Spontaneous  gastric  fis- 
tula.— Sites  for  opening  the  stomach. — Fixation  into  the  abdom- 
inalwall. — Attaching  the  abdominal  wound  with  the  gastric 
mucous  membrane. — Drainage-tube* — Obturators. — Co?idition 
of  the  patient  in  gastric  fistula. — Artificial  {external)  oesopha- 
gus.— Opening  the  duodenum. — Closing  gastric  Fistula. — 
Anomalous  anus. — Atresia  ani. — Degrees  of  defectus 
ani  et  recti. — Opening  atresic  anus. — Lumbocolotomy. — 
Laparocolotomy. — Fistula  of  small  intestines. — Artificial 
Anus. — Foreign   bodies   in    the   rectum   and   in   the 

VAGINA. 

While  cesophagotomy  permits  the  introduction  of  food 
through  a  wound  made  into  the  oesophagus,  when  an  im- 
permeable stricture  about  the  level  of  the  larynx  occludes 
it,  deeper  impediments  for  the  passage  of  food  as  are  all 
impermeable  strictures,  that  is,  those  which  even  in  narcosis 
are  intransitable,  in  the  thoracic  part  of  the  oesophagus, 
will  require  direct  introduction  of  food  into  the  stomach 
through  a  wound  of  that  organ,  as  the  only  means  by  which 
to  save  the  affected  individuals  from  death  by  starvation. 

Gastrotomy*  is  not  only  indicated  in  the  above  cited  cases 
where  entire  stenosis  of  the  oesophagus,  or,  at  least,  non- 
dilatable  centrifugal  strictures,  as  a  consequence  of  ulcera- 
tion or  cauterization,  of  acids  or  alkalies  occurs,  but  also  in 
those  strictures  which  are  still  permeable  when  they  depend 
upon  the  growth  of  tumors  (cancers)  in  the  oesophageal  walls. 
Here,  as  in  rectal  carcinoma  (Curling),  to  permanently  re- 
move the  irritation  of  the  tumefied  masses,  such  as  is 
brought  about  by  the  frequent  introduction  of  instruments 

*  Many  choose  to  speak  of  Gastrostomy, or  the  opening  of  agastric  fistula, 
in  distinction  to  Gastrotomy,  incision  of  the  stomach.  Gastrotomy  would 
mean  only  temporary  opening  of  the  stomach;  but  gastrostomy  was  to 
apply  to  a  permanent  opening  for  continuous  nutrition.  We  consider 
these  distinctions  as  superfluous  and  confusing,  and  will  retain  only  the 
term  gastrotomy.  The  term  gastrotomy  as  a  designation  for  abdominal 
incision  (laparotomy)  is  frequently  abused  in  England  and  Italy. 


120  SURGICAL   EMERGENCIES. 

for  the  purpose  of  dilation  and  nutrition,  gastrotomy  is 
undertaken,  and  thus  the  danger  of  disintegration  of  the 
tumor  is  avoided  (Billroth*).  A  further  indication  for  open- 
ing the  stomach  is  when  substances  are  swallowed  whose 
dimensions  preclude  their  passage  through  the  intestinal 
canal.  Among  these  may  be  considered  forks  and  knives, 
which  frequently  have  given  cause  for  direct  opening  of 
the  stomach.  Also  needles  may  require  it.  It  is  safe  to  say 
that  they  but  very  rarely  penetrate  the  gastric  walls,  thence 
to  take  up  their  migrations  through  the  organism.  Most  of 
them  probably  remain  in  the  stomach  or  intestines,  become 
imbedded  in  the  mucous  membrane,  or  when  unfavorable 
circumstances  prevail  cause  an  abscess  in  the  gastric  walls 
which  penetrates  the  abdominal  parietes  and  empties  out- 
wards, thus  to  discharge  the  foreign  body.  Needles  found 
in  the  subcutaneous  connective  tissue  in  various  parts  of 
the  body,  which  it  is  claimed  have  migrated  from  the 
stomach,  are  to  be  treated  with  great  circumspection,  as 
herein  a  number  of  intentional  deceptions  on  the  part  of 
patients  are  on  record  (Hager,f  Pollock,^  Doran§). 

Furthermore,  after  it  shall  have  become  possible  to  diag- 
nose cancer  of  the  stomach  earlier  than  it  can  be  as  yet 
(Van  der  Velden||)  opening  the  stomach  according  to  the 
experiments  of  Gussenbauer  and  von  Winiwarter,^"  will  be 
used  not  only  for  the  establishment  of  a  gastric  fistula,  but 
also  for  excision  of  the  part  of  the  stomach  which  has  suf- 
fered cancerous  degeneration  (perhaps  most  frequently  the 
pyloric  portion). 

Finally,  it  has  been  proposed  to  dilate  strictures  of  the 
cardiac  as  well  as  pyloric  ends,  through  openings  made  into 
the  anterior  walls  of  the  stomach.  At  all  events,  no  great 
difficulties  will  attach  to  inserting  sounds  into  the  cardiac 
and  pyloric  ends  through  the  abdomino-gastric  wound. 

*  Billroth,  VI.  Congress  d.  deutsch.  Gesellsch.  f.  Chir.  1877.  I.  p.  105. 

f  Hagen,  die  Fremden  Korper  in  Meiischen.  Wien,  1844. 

X  Pollock,  Holmes'  System  of  Surgery.  2nd.  ed.  Art.  Injuries  of  the 
Abdomen. 

§  Doran,  Foreign  bodies  imbedded  in  the  tissues.  St.  Bartholomew's 
Hosp.  Rep's.  1876,  pp.  113  to  124. 

I  Van  der  Velden,  Ueber  Vorkommer  und  Mangel  d.  freien  Salzsaure 
in  Magensaft,  etc.  Deutsches  Archiv.  f.  klein  Med.  Bd.  XXIII. 

TT  Gussenbauer,  and  v.  Winiwarter,  Die  pertielle  Mageuresection. 
Arch.  f.  Klin.  Chir.  Bd.  XIX.  Heft.  3.  (It  was  proposed  by  Merren  in 
1810.  Sprengel  [Gesehiclete  d.  Chirurgie]  designated  the  proposition 
as  "  Merrem's  Dream"). 


SURGICAL  EMERGENCIES.  121 

It  is  said  that  on  July  9th,  1635,  Daniel  Schwabe,  of 
Konigsberg,  removed  a  table-knife  by  gastrotomy,  before 
the  medical  faculty  of  that  place.  More  than  two  hundred 
years  later  Sedillot*'  (Strassburg,  1849)  made  a  gastrotomy 
for  nutrient  purposes  in  impermeable  stenosis  of  the  oeso- 
phagus (gastrostomy).  His  first  operations  were  made  in 
the  linea  alba,  and  two  years  later  he  transferred  the  in- 
cision to  the  left  hypochondrium.  Fengerf  adopted  this 
latter  plan  long  ago,  and  executed  it  scientifically.  Recently 
VerneuilJ  and  Labbe§  made  the  operation,  and  to-day  the 
greater  part  of  operators  have  joined  them,  adding  the  ap- 
plication of  antiseptics. 

Besides  operative  opening  of  the  stomach,  as  we  will  learn 
to  make  it,  so-called  spontaneous  gastric  fistula  may  occur, 
which  are  produced  either  traumatically,  as  after  a  stab 
into  the  stomach,  or  in  profound  or  chronic  or  cancerous 
tumors  of  the  gastric  walls  which  cause  their  union  with 
the  abdominal  coverings,  and  ulcerations  occur  which  attack 
the  entire  abdominal  parietes,  including  the  skin. 

The  sites  at  which  the  abdominal  walls  have  been  opened 
to  reach  the  stomach  are  the  linea  alba,  undoubtedly  the 
most  recommendable  place  ;  furthermore,  in  a  line  parallel 
to  the  linea  alba,  at  the  lateral  margin  of  the  left  rectus 
abdominis  muscle,  and  finally  an  incision  below  the  left 
free  margin  of  the  ribs,  parallel  to  them  and  about  3  to  4  cm. 
below  them. 

After  incising  the  abdominal  wall,  carefully  controlling 
haemorrhage  which,  when  the  linea  alba  is  selected,  will  be 
least,  the  anterior  wall  of  the  stomach  is  reached  directly, 
when  it  is  filled,  as  under  ordinary  circumstances.  In  such 
cases  as  require  gastrotomy  because  of  danger  of  starvation 
in  impermeability  of  the  oesophagus,  the  stomach  is  found 
collapsed  and  drawn  backwards  and  upwards  against  the 
diaphragm,  thus  making  its  finding  difficult,  more  so  when, 
as  it  frequently  occurs,  the  transverse  colon  is  tympanitic 
and  presents  itself.  If  care  were  not  employed  there  might 
be  danger  of  opening  the  colon  instead  of  the  stomach. 
To  avoid  errors  we  should,  in  seeking  for  the  stomach,  be  guided 

*  Sedillot,  Comptes  rendus  de  l'acad.  des  sciences.     Paris,  1849. 

f  Fengen,  (Kopenhagen).  Virchovv's  Archiv.  Bd.  VI.  p.  350. 

X  Verneuil,  Gaz.  Med.  de  Paris,  1876;  No.  44. 

§  Labbe,  Note  relative  a  un  fait  de  gastromie  prartiquee  pour  extraire 
un  corps  etranger  (fourchette)  de  l'estomac.  Comptes  rendus  de  l'acad. 
de  m6d.  LXXXII.  No.  17,  and  Gaz.  des  Hopit.  1877,  No.  49. 


122  SURGICAL  EMERGENCIES. 

by  the  gastroepiploic  vessels,  above  which  the  greater  curva- 
ture of  the  stomach  is  inevitably  found  (Trendelenburg*) 
If  the  operation  be  made  for  cancerous  or  still  permeable 
strictures  of  the  oesophagus,  the  measures  recommended 
by  Schreiber  and  first  employed  by  Schonborn,f  may  be 
required.  They  consist  of  inserting  an  oesophageal  sound 
into  the  stomach;  the  sound  has  a  rubber  balloon  attached 
to  its  end.  As  soon  as  the  balloon  reaches  the  stomach  it 
is  inflated,  whereby  the  anterior  gastric  wall  is  pressed 
against  the  abdominal  wound. 

Various  opinions  prevail  as  to  the  order  in  which  the 
further  steps  of  the  operation  should  be  made.  As  in  open- 
ing intra-abdominal  cystic  tumors  (echinococci),  we  must 
be  guided  by  the  thought  that  it  is  desirable  first  to  accom- 
plish an  adhesion  between  the  anterior  and  posterior  gas- 
tric walls,  and  to  open  the  stomach  subsequently.  Thus  a 
needle  is  inserted  into  the  anterior  gastric  walls  and  allowed 
to  lie  external  to  the  abdominal  coverings,  and  further  steps 
are  deferred  to  a  second  seance,  at  which  sutures  are  in- 
serted between  the  walls  of  the  abdomen  and  stomach,  and 
the  stomach  opened  between  the  sutures.  Others,  again, 
filled  the  wound  in  the  abdominal  wall  with  a  ball  of  Lis- 
ter's gauze  to  produce  adhesion  and  incise  the  stomach 
subsequently.  This  means  is  less  safe  than  the  former. 
But  little  importance  can  be  attached  to  the  production  of 
protective  adhesions  in  this  manner.  If  it  be  remembered 
that  gastrotomy  gained  ground  after  the  value  of  strict 
observance  of  antiseptic  rules  became  appreciated,  and  if 
it  be  considered  that  neoplasmic  connective  tissue  forma- 
tion is  slower  and  less  in  degree  than  under  the  influence 
of  stronger  irritations  to  the  tissues,  we  must  say  that  the 
formation  of  sufficiently  strong  adhesions  without  sutures 
can  be  counted  upon  only  when  as  great  a  length  of  time 
as  possible  is  allowed  to  intervene  between  splitting  the 
abdomen  and  opening  the  stomach.  This  should  be  fol- 
lowed in  cancerous  strictures,  and  where  the  strength  of  the 
patient  justifies  the  expectation  of  a  sufficient  reaction  on 
the  part  of  the  tissues. 

At  all  events,  immediate  sewing  of  the  stomach  to  the 
abdominal  wall  will  produce  adhesions  and  yield  an  im- 

*  Frendelburg,  Archiv.  f.  Klin.  Chir.  1877,  Bd.  XXII.  Heft.  1. 
f  Schonborn,  Archiv.  f.   Klin.  Chir.  1878,  Bd.  XXII.  Heft.  2,  and  Ver- 
handl.  d.  VI.  Congr.  d.  deutsch.  Gesellschaft  f.  Chir.  vora  Jahr,  1877. 


SURGICAL  EMERGENCIES.  1 23 

mediate  sequestration  of  the  abdominal  cavity  outwards. 
In  complete  impermeability  of  the  cesophaghus,  when  the 
patient  is  near  starvation  and  where  nutrition  is  not  suffi- 
cient by  clysters  or  cannot  be  executed,  we  must  immediately 
proceed  to  the  introduction  of  food  into  the  stomach.  It 
appears  according  to  the  successful  cases  that  as  yet  have 
been  recorded  that  the  above  method  of  the  production  of 
agastric  fistula  in  one  sitting  merits  preference  to  all  others 
(Kaiser's*). 

After  the  stomach  is  found,  a  fold  of  its  anterior  wall  is 
drawn  out  of  the  abdominal  wound  with  two  forceps.  But 
care  must  be  taken  not  to  grasp  the  tissues  too  deeply  towards 
the  greater  curvature.  The  forceps  are  substituted  by  two 
stout  silk  threads.  At  the  circumference  of  the  base  of  the 
fold  of  the  stomach,  thus  drawn  forth,  sutures,  preferably 
of  medium  catgut  or  carbolized  silk  threads,  are  placed. 
These  are  inserted  encompassing  the  serous  membrane  and 
muscles  of  the  stomach  without  perforating  the  mucous 
membrane,  but  taking  in  the  serous  membrane  of  the 
abdomen  at  a  greater  circumference  and  more  or  less  of  the 
abdominal  muscles,  according  to  the  thickness  of  the  ab- 
dominal wall.  Greater  care  must  be  exercised  in  inserting 
the  sutures  at  both  the  angles  of  the  abdominal  wound. 

Within  the  circle  of  sutures  thus  formed  lies  the  fold  of 
stomach  which  has  been  drawn  out  and  this  must  now  be 
incised  at  the  apex  of  its  convexity.  It  would  be  well  now 
to  unite  the  margins  of  the  gastric  mucous  membrane  with 
the  lips  of  the  wound  in  the  skin.  The  union  of  the  skin 
with  gastric  mucous  membrane,  for  which  thin  silk  thread 
is  used,  prevents  the  formation  of  dissecting  abscesses  be- 
tween the  abdominal  muscles,  which  frequently  have  been 
observed  after  gastrotomy. 

The  longitudinal  diameter  of  the  gastric  fistula  will  have 
its  direction  changed  according  to  whether  the  abdomen 
is  opened  in  the  linea  alba  or  beneath  the  left  margin  of  the 
ribs. 

If  the  wound  be  made  at  the  latter  place,  the  ends  are 
more  easily  reached  and  nearly  all  haemorrhage  is  avoided, 
when,  after  the  incision  is  made  the  following  steps  are 
taken  :  The  incision  begins  at  the  outer  margin  of  the  left 
rectus  abdominis,  and  is  continued  some  3  to  4  cm.  below 

*  Kaiser,  Beits,   z.   d.  operation  am  Magen.     In  V,   Czerny's  Beitr.  z. 
op.  Chir.  Stuttgart,  1878. 


124  SURGICAL   EMERGENCIES. 

the  margin  of  the  ribs  and  runs  slightly  concave  to  them  ; 
the  abdominal  muscles  must  not  be  incised  in  the  same 
direction  without  consideration  of  the  course  of  their  fibres, 
but  each  muscle  that  lies  within  the  regiofi  is  drawn  apart  with 
blunt  hooks  according  to  the  direction  of  its  fibres.  Notwith- 
standing the  various  directions  of  the  fibres,  a  good  gaping 
wound  results. 

A  short  thick  drainage-tube  is  to  be  fastened  immediately 
into  the  cavity  of  the  stomach  ;  through  it  the  stomach  can 
be  frequently  washed  out  and  food  may  be  introduced  by 
it  (Verneuil,  /.  c.)  It  is  recommendable  to  use  a  very  wide 
tube  so  that  large  solid  bits  of  meat  may  be  introduced 
into  the  stomach  which  will  require  less  digestive  power  of 
the  stomach  in  reference  to  the  amount  of  gastric  secretion 
used,  than  nutriment  in  greater  volume,  as  fluids,  or  in 
pieces  of  greater  superficial  surface,  as,  for  instance,  scraped 
meat. 

The  further  course  of  treatment  may  allow  the  substitu- 
tion of  the  drainage-tube  by  variously  formed  obturators, 
consisting  of  a  short  cylinder  with  two  plates  screwed  to  it, 
one  for  the  gastric  wall,  the  other  for  the  abdominal  wall, 
such  as  are  used  for  physiological  investigations,  or  tubes 
may  be  used  resembling  tracheal  tubes,  and  having  a  broad 
shield  for  the  abdomen.  The  advantage  of  such  obtura- 
tors is  evident  only  when  the  gastric  fistula  has  been  made 
near  the  greater  curvature,  and  as  a  consequence  allows  food, 
especially  in  a  fluid  form,  to  soon  flow  out  again.  Inasmuch 
as  digestion  does  not  take  place  or  is  very  incomplete, 
despite  the  fistula  proper,  plugging  by  a  good  obturator  will 
relieve  the  trouble  at  least  in  good  part.  Still,  obturators 
frequently  produce  undesirable  enlargement  of  the  fistula 
and  must  be  entirely  omitted. 

Patients  in  whom  nutrition  has  been  established  by  in- 
troduction of  food  directly  into  the  stomach,  recover  and 
rapidly  increase  in  weight,  if  no  cancerous  stenosis  of  the 
stomach  obtains.  They  retain  the  sensations  of  hunger  and 
thirst,  and  endeavor  to  satisfy  the  latter  by  taking  fluids,  by 
the  mouth,  which  after  being  swallowed  reach  only  as  far 
as  the  stenosis  and  then  are  regurgitated.  The  sensation 
of  taste,  as  is  incidental  to  taking  food  by  the  mouth,  is 
lost.  For  the  purpose  of  delivering  food  to  the  stomach  in 
a  most  natural  condition  Trendelenburg  (/.  c.)  attached  a 
rubber  tube  to  his  patient's  fistula- tube,  which  rubber  tube 
was  long  enough  to  reach  the  patient's  mouth.     He  could 


SURGICAL  EMERGENCIES.  125 

chew  his  food,  mix  it  with  saliva  and  liquids,  and  propel  it 
into  his  stomach  through  the  rubber  tube,  making  it  as  it 
were,  an  artificial  oesophagus. 

In  inoperable  carcinomata  of  the  stomach  or  non-dilatable 
strictures  of  the  pylorus  it  has  been  suggested  to  open  the 
duodenum  directly  through  the  abdominal  walls  and  to 
use  it  for  the  introduction  of  food,  thus  excluding  and  re- 
lieving the  stomach  (Schede.*)  As  yet  but  isolated  cases 
which  have  been  operated  on  in  this  manner  are  recorded, 
yet  the  probabilities  of  success  of  such  a  procedure  are  not 
to  be  denied  for  the  future.  Kaiser  (/.  c.)  has  shown  that 
the  organism  can  continue  to  exist  after  entire  or  almost 
entire  excision  of  the  stomach. 

How  shall  we  succeed  in  closing  gastric  fistula  of  trauma- 
tic or  ulcerative  origin  ?  If  the  margins  of  the  fistula  are 
freshened  and  a  flap  transplanted  from  the  vicinity,  it  may 
heal  quite  well,  but  as  the  circulation  in  the  flap  is  much  less 
developed  than  in  the  rest  of  the  skin,  it  may  succumb  to 
the  influence  of  the  gastric  juice  and  gradually  be  digested. 
The  healthy  abdominal  integument  has  been  observed  to 
show  fissures  like  sites  of  corrosion  where  the  gastric  juice 
could  flow  out  upon  it.  This  is  to  be  attributed  to  the 
above  cause  (Rosef). 

Permanent  closure  of  large  gastro-abdominal  fistulas  is 
accomplished  only  by  dissecting  the  stomach  from  the 
wound  in  the  abdominal  coverings,  and  closing  the  gastric 
wound.  Then  the  interval  in  the  abdominal  wall  is  closed 
by  a  suture  or  covered  by  a  transplanted  flap  of  skin 
(Billroth!). 

The  treatment  of  abnormalities  which  occur  at  the  lower 
orifices  of  the  intestinal  canal  and  prevent  or  render  diffi- 
cult the  evacuation  of  faeces  must  be  discussed  in  this  con- 
nection. First,  we  will  consider  abnormal  termination, 
closure,  and  absence  of  the  anal  opening  (anus  anomatus, 
atresia  ani,  defectus  ani). 

Abnormal  anus  opens  either  anywhere  in  the  skin  in  the 

*  Schede,  Verhandl.  d.  VI.  Congr.  d.  deutsch  Gesullsch.  f.  Chir.  1877, 
I.  p.  107. 

f  Rose.  Ueber  einen  eigenthiiml.  zufall  n.  Gastrotomie.  Corresp. 
Blatt.  f.  Schweizer  Aerzte,  1879. 

\  Billroth,  Gastrosaphie.  Wien.  Med.  Wocenschr,  1877,  No.  38.  Com, 
pare  Wolfler,  Die  Mangen  banchwandfistel,  etc.  Archiv.  f.  klin.  Chir.  Bd. 
XX.  Heft  3. 


126  SURGICAL  EMERGENCIES. 

neighborhood  of  the  pelvis  (anus  anom.  ext.)  as  in  the 
sacral  or  hypogastric  region  (Littre),  or  in  the  umbilical  re- 
gion (Merie),  or  in  the  pudenda  or  even  at  the  penis  (Wilkes). 
Or  we  will  have  to  deal  with  an  opening  of  the  anus  into 
the  bladder,  into  the  vagina  or  the  urethra  (anus  anom. 
int.).  In  all  of  these  cases  an  opening  of  the  anus  into 
the  vagina  is  the  most  favorable,  because  there  the  least 
impediment  is  offered  to  the  evacuation  of  firm  faecal  balls. 
The  most  difficult  evacuation  of  faeces  is  through  the  male 
urethra.  The  vaginal  anus  is  the  easiest  to  treat  opera- 
tively,  e.g.,  it  can  be  removed  with  greater  facility  from  the 
vagina  and  attached  to  the  normal  anal  opening. 

Closure  of  the  anal  opening  depends  either  upon  a  ter- 
mination of  the  rectum  in  a  cul-de-sac  in  the  upper  perineal 
region,  or  upon  a  funnel-like  contraction  of  the  anal  opening 
at  its  normal  place,  but  above  the  funnel  there  is  no  sig- 
moid flexure  to  the  colon,  or  finally  an  entire  arrest  of  de- 
velopment of  the  rectal  division,  or  of  the  colon  as  far  even 
as  the  right  iliac  fossa. 

Direct  operative  procedures  are  admissible  only  in  cases 
of  atresia  ani  where  the  rectum  still  exists  for  some  dis- 
tance above  the  perineum,  and  where  at  least  a  part  of  the 
sigmoid  flexure  is  developed.  The  operation  must  be  per- 
formed within  a  few  days  after  birth  if  the  child  is  not  to  be 
allowed  to  die. 

The  perineal  raphe  is  incised,  the  cut  beginning  immedi- 
ately before  the  coccyx;  the  connective  tissue-layers  con- 
taining more  or  less  fat  are  pushed  apart,  the  index-finger 
is  bored  in  until  it  strikes  the  proctodaeum,  which  may  then 
be  opened.  The  higher  the  intestine  lies  above  the  perineum 
the  mo're  difficult  will  it  be  to  find  it,  and  the  more  it  must 
be  drawn  down  to  unite  the  wound  in  the  integument  with  the 
lower  free  margin  of  the  rectal  mucous  membrane.  All  effort 
must  be  made  to  do  the  latter,  partly  to  avoid  the  faecal 
infiltration  of  the  periprocteal  connective  tissue,  and  also  to 
prevent  contraction  of  the  newly-made  anal  opening.  Such 
strictures  of  the  newly  made  anal  opening,  like  those  of  the 
urethra  require  prolonged  treatment  with  dilating  instru- 
ments (finger-plugs  of  tin). 

It  has  been  proposed,  in  entire  absence  of  the  sigmoid 
flexure,  when  it  was  desired  to  succeed  in  obtaining  an 
anal   opening  in  the  perineum,  to  lay  free  the  descending 

*  Wilkes,  Med.  Times  and  Gaz.  1875,  July  24,  p.  op 


SURGICAL  EMERGENCIES.  127 

colon  in  the  left  abdominal  cavity,  to  open  it  and  to  insert 
a  thick  bougie.  The  latter  then  pushes  the  cul-de-sac  of 
the  gut  so  deeply  against  the  wound  made  into  the  peri- 
neum that  it  will  allow  cutting  down  upon  the  point  of  the 
bougie  (Martin).  Dlauhy's  proposition  appears  less  feasible. 
He  proposed  to  open  the  abdomen  in  the  lineaalba  or  in  the 
left  inguinal  region  and  to  seek  the  cul-de-sac  with  the  fin- 
ger through  these  wounds  (Kotzmann*). 

Most  of  these  cases  will  probably  preclude  sewing  the 
anal  opening. 

But  if  the  large  intestine  cannot  be  reached  in  any  man- 
ner from  the  perineum  we  will  have  to  content  ourselves 
with  the  production  of  a  preternatural  anus.  The  operation 
will  be  made  on  the  left  side  where  the  descending  colon 
exists,  and  on  the  right  side  when  it  is  absent. 

Colotomy,  opening  the  large  intestine  through  the 
abdomen,  will  have  to  be  performed  in  total  absence  of  the 
lower  end  of  the  large  intestine,  in  impermeable  strictures, 
or  in  deformities  of  the  rectum  as  well  as  inoperable  rectal 
cancer  with  considerable  contraction.  The  same  principles 
which  we  detailed  in  the  discussion  of  cancerous  strictures 
of  the  oesophagus  and  pylorus  hold  good  in  this  operation, 
(Curling,  Bryant;  compare  Lecture  VIII.) 

Two  methods  have  thus  far  been  generally  recognized; 
they  are  Lumbocolotomy  and  Laparocolotomy.  Duret 
repeatedly  made  both  of  these  towards  the  end  of  the  last 
century.  Littre  proposed  laparocolotomy  as  early  as  17 10, 
and  Pillore  performed  it  in  1776  for  rectal  cancer.  The 
English  claim  lumbocolotomy  for  Callisen  (1813).  Amus- 
sat  again  recommended  it  between  1840  and   1850. 

Lumbocolotomy  is  intended  for  opening  the  descending 
colon  at  its  posterior  surface  where  it  is  said  not  to  be  cov- 
ered with  peritoneum.  Midway  between  the  left  arch  of 
the  ribs  and  the  middle  third  of  the  left  crest  of  the  ileum 
an  incision  is  made  into  the  skin  begining  parallel  to  both 
those  points,  along  the  lateral  margin  of  the  sacrolumbar 
muscle.  Then  the  deeper  parts  are  cut  until  the  gut  is 
reached,  which  is  best  opened  parallel  to  its  long  axis.  It 
would  appear  more  convenient  to  incise  as  before,  and  to 
continue  along  the  lateral  side  of  the  quadratus  lumborum 
from  the  margin  of  the  ribs  to  the  crest  of  the  ileum. 
Konig  (Lehrbuch,    Bd.    II.    p.    309)    describes  an  incision 

*  Kotzmann,  Wiener  Med.  Wochenschr.  1877,  Nos.  23  and  24. 


128  SURGICAL  EMERGENCIES. 

diagonally  forwards,  descending  to  the  anterior  superior 
spine  of  the  ileum.  But  lumbocolotomy  does  not  appear 
to  be  a  recommendable  operation;  firstly,  because  of  the 
great  depth  of  the  wound;  secondly,  because  of  the  diffi- 
culty of  finding  the  colon;  thirdly,  because  the  alleged 
advantage  of  extraperitoneal  access  is  illusory,  inasmuch 
as  the  peritoneal  covering  of  the  descending  colon  but 
seldom  is  absent  from  its  posterior  surface  (in  children  a 
mesocolon,  even,  is  often  found);  and  fourthly,  because  the 
inconveniences  of  a  lumbar  anus  are  much  greater  than 
those  situated  in  the  inguinal  region  (von  Erckelens*). 

As  much  as  antiseptic  precautions  deprive  intraperitoneal 
operations  of  their  dangers,  so  much  will  we  give  prefer- 
erence  to  making  a  supra-inguinal  anus  to  laparocolotomy. 
Furthermore  it  is  far  more  easily  executed.  In  rectal  can- 
cer extending  high  up,  as  in  absence  of  the  sigmoid  flexure, 
we  will  operate  on  the  left  side;  while  in  impediments 
higher  up,  and  in  absence  of  the  entire  descending  colon, 
we  will  select  the  right  side.  The  abdominal  coverings 
over  the  gut  are  slit  parallel  to  the  longitudinal  axis  of 
the  colon  by  an  incision  begining  2  to  3  cm.  inwards  and 
upwards  of  the  ant.  sup.  spine  of  the  ileum,  and  descending 
towards  the  mesian  line  in  somewhat  of  a  convex  curve  to 
Poupart's  ligamet.  The  gut  is  fixed  and  opened  according 
to  the  same  rules  as  have  been  detailed  for  gastrotomy. 

Exactly  the  same  rules  govern  making  fistula  of  the 
small  intestines,  after  opening  the  abdomen  for  internal 
strangulation  or  invagination  of  the  intestine  without  being 
able  to  find  the  site  of  the  disturbance.  It  is  hardly  neces- 
sary to  mention  that  the  loop  to  be  selected  should  be  the 
one  which  is  distended  by  its  contents,  consequently  one 
which  is  above  the  difficulty.  In  colotomy,  as  in  restora- 
tion of  fistulse  in  the  small  intestines,  the  entire  operation 
should  be  made  in  one  sitting,  and  only  exceptional  cases 
will  permit  opening  the  intestine  to  be  deferred  24  or  48 
hours  after  application  of  the  abdominal  sutures. 

We  will  close  briefly  with  the  treatment  of  fareign  bodies 
in  the  rectum.      Stercoraceous  calculi  often  of  considerable 

*Van  Erckelen's,  Ueber  Colotomie,  speciel.,  b.  Mastdermstenose 
durch  Carcinom.  Mang.  Diss.  Bonn,  1876.  The  same  contains  also 
statistical  compilations  of  Hawkins,  Mason,  Tungel,  Curling,  Allingham, 
(St.  Thomas's  Hosp.  Rep.  1870,  I.  p.  285.)  and  Adelman,  (Prayer  Vier- 
teljahschr.  1863),  and  more  extensive  bibliography. 


SURGICAL  EMERGENCIES.  I2g 

dimensions,  have  been  found  in  the  rectum,  as  have  been 
a  great  variety  of  articles  which  were  inserted  from  without. 
Small  rounded  bodies  are  removed  with  the  faeces  or  by 
copious  injections  of  water.  Large  angular  bodies  first  re- 
quire injections  of  weak  carbolized  oil  or  similar  vaseline  (2 
to  3  per  cent),  then  they  may  be  extracted  with  the  fingers  or 
grasping  instruments  (forceps),  or  they  may  be  levered  out 
with  lithotomy-scoops.  When  very  large,  or  fragile  articles, 
(tumblers,  pomade-pots)  occupy  the  rectum,  no  effort  must 
be  made  to  fracture  them,  but  the  patient  must  be  narco- 
tized, and  after  forcibly  delating  the  rectum,  the  foreign 
body  must  be  levered  out  by  means  of  the  index-finger 
bent  into  hook-like  form.  The  latter  course  must  also  be 
pursued  in  the  removal  of  pointed  or  sharp  articles,  especi- 
ally when  they  have  penetrated  the  rectal  mucous  mem- 
brane. In  such  cases  specula  must  be  used,  through 
which  to  grasp  sharp  bodies  without  injury  to  the  rectal 
mucous  membrane,  and  after  separating  them  to  remove 
them.  (Compare  Marchetti's  Case,  in  Lecture  III.).  Similar 
principles  govern  the  removal  of  foreign  bodies  fro?n  the  vag- 
ina. But  in  these  cases  exploration  of  the  rectum  and 
bladder  are  of  great  importance  in  each  case,  especially 
when  the  foreign  body  is  a  sharp  one,  as  it  may  have  per- 
forated the  anterior  or  posterior  vaginal  septum.  Barbed 
articles  should  always  be  extracted  through  a  speculum. 
The  bodies  most  frequently  to  be  removed  from  the  vagina 
are  perhaps  neglected  pessaries,  which  have  been  partly 
encrusted,  and  partly  held  in  abcess-cavities  formed  in  the 
peri-vaginal  tissues.  These  bodies  may  be  broken  up  be- 
fore extraction,  thus  facilitating  it.  Needles,  which  pro- 
ject into  the  rectum  or  bladder,  may  be  cut  in  two  and  one 
half  removed  from  the  vagina  and  the  other  from  the 
rectum  or  bladder  as  the  case  may  be. 


T30  SURGICAL  EMERGENCIES. 


LECTURE  X. 

Dangerous  impedime7its  to  respiration  and  circulation  resultant 
upon  accumulation  or  retention  of  fluids  within  the  cavities  of 
the  body,  within  certain  hollow  organs  and  within  pathological 
cystic  spaces. 

Accumulations  of  Fluids  within  the  Thorax. — Historical 
considerations. — I?zdications  for  the  evacuation  of  pleuritic  exu- 
dations in  general. — Re-absorption  by  the  pleura. — Pneumotho- 
rax, chlylothorax,  hozmatothorax. —  Treatment  of  punctures  into 
the  pleura. — Opening  of  the  thorax  and  special  indications  there- 
for.— Punctio  Thoracis  :  Thoracotomy. — Sites  for  opening 
the  thorax. — Puncture  of  the  thorax. — Hcemorrhage  from  the 
intercostal  vessels. — Trocars. — Apparatus  for  puncture  with  ex- 
clusion of  air . — After-treatment  of  puncture. — Opening  the 
Pleura  by  Incision. — Partial subperisosteal excision  of  ribs. 
— After  treatment  subsequent  to  the  production  of  thoracic  fistula. 
— Accumulations  of  fluids  and  air  in  the  p eric ardiitin  and  their 
treatment. —  Wounds  in  the  heart. — Electropzmcture  and  acu- 
puncture of  the  heart. 

Gentlemen:  My  object  in  adding  a  brief  historical  re- 
view to  this  chapter  is  to  offer  you  therein  that  most  in- 
structive example  of  the  historical  development  of  medicine 
in  general,  which  it  especially  contains. 

You  can  convince  yourselves  that  the  views  which  are 
brought  forward  herein,  and  that  the  therapeutic  principles 
which  still  are  accepted  to-day,  were  recognized  since  remote 
antiquity  when  they  existed,  only  in  another  form,  and  that 
the  progress  which  we  claim  to  have  made  in  our  present 
treatment  of  the  matter  really  refers  only  to  more  complete 
diagnosis  and  greater  security  in  the  calculation  of  curative 
results. 

Hippocrates  recognized  and  diagnosticated  accumulations 
of  fluids  in  the  thoracic  cavity  (Succussio  Hippokratis). 
Accumulations  of  pus  were  treated  by  opening  the  thoracic 
cavity  with  a  knife  or  red-hot  iron.  Preference  was  given 
to  the  knife.  Arabian  surgery  applied  the  red-hot  iron  in 
the  treatment  of  pleural  effusions  to  produce  an  eschar  of 


SURGICAL  EMERGENCIES.  131 

the  thoracic  wall  and  to  open  the  pleural  cavity  through  the 
eschar.  Fabricius  ab  Aquapendente  and  Pare  recommended 
opening  the  pleural  cavity  with  a  knife.  In  difficult  evacu- 
ation of  pus,  Pare  trephined  a  rib  and  used  the  tense  open- 
ing thus  obtained  as  a  means  of  outflow  for  the  pus,  while 
Fabricius  advocated  opening  the  thorax  between  the  fifth 
and  sixth  ribs.  About  1760  the  younger  Monro  added  to 
the  indications  for  opening  the  chest  in  pyothorax  and  pyo- 
pneumo  thorax,those  of  the  operative  procedures  in  accumu- 
lations of  pure  air  within  the  pleural  cavity  to  which  Itard  * 
(1803)  gave  the  name  of  pneumothorax. 

Soon  it  was  suggested  to  remove  the  pleural  contents 
with  suction-apparatus  after  it  had  been  learned  to  open  the 
thorax  with  a  trocar  instead  of  a  knife  (Heister,  Lurde,  1765). 
In  natural  sequence  the  idea  of  evacuating  pleuritic  exuda- 
tions, under  exclusion  of  the  air,  was  added  to  the  former 
suggestions.  (Krausef,  SchuhJ,  Wintrich§,  Roser  ||,  Kuss- 
maul^f,  Bartels**.)  Present  times  brought  forth  Dieula- 
foy's  ft  apparatus  which  popularized  aspiration  of  pleuritic 
exudations  to  such  a  degree  that  the  calls  for  opening  the 
pleura  by  incision  and  puncture  began  to  fade  in  profess- 
ional favor. 

Previous  to  establishing  the  special  indications,  we  will 
elucidate  which  pleural  effusions  should  be  evacuated  and 
when  this  should  be  done  (compare  also  Krause,  I.e.). 

1.  The  operation  must  be  made  when  the  effusion  into 
the  pleura  imperils  vital  organs,  possibly  because  of  its  large 
quantity,  or,  what  merits  equal  consideration,  by  its  rapid  accu- 
mulation. 

A  pleuritic  effusion  which  compresses  a  lung  entirely  or 
crowds  the  heart  out  of  position  and  causes  even  the  medi- 


*  Itard,  Sur  le  pneumothoror  ou  les  congestions,  qui  se  forment 
dans  la  poitrine.     These  de  Paris,  1803. 

f  Krause,  Das  Empyem  und  seine  Heilung  Danzig,  1843, 

%  Schu — Skoda,  Ueber  die  Entlecrung  pleuritischer  Exsudate  Oesten 
Jahrbiicher  1841,  1842,  1843. 

§Wintrich,   Kraukheiten    der  Respira   tionsorgane.     Erlangen,   1854. 

\  Roser,  Tur  Operation    des    Empyerus.     Archiv.  f.  Keilkunde,  1865. 

^[  Kussmaul,  Sechszehn  Beobachtungen  von  Thoracoceutese  beipleu- 
ritis,  etc.     Archiv.  f.  klin.  Med.  Bd.  IV. 

**  Bartels,  Ueber  die  operative  Behandlung  der  entriundlichen  Exsu- 
date im  Pleurasack.     Archiv.  f.  klin.  Med.  Bd.  IV.  p.  263. 

ft  Dieulafoy,  Du  diagnostic  et  du  traitement  des  epauchements  aigus 
st  chroniques  de  la  plevre  par  aspiration.  Bull,  gener.  de  ther.  30  Juin, 
1872. 


132  !  SURGICAL  EMERGENCIES. 

astinal  space  to  bulge  towards  the  other  pleural  cavity,  re- 
duces the  respiratory  surface  in  a  more  dangerous  degree 
when  the  condition  of  the  other  lung  is  not  normal  or  where 
rapid  accumulations  cause  rapid  and  more  marked  reduction 
of  the  respiratory  surface.  But  this  is  not  the  only  impor- 
tant question  which  merits  consideration  in  this  connection. 
We  know  experimentally  that  the  main  bronchus  of  a  lung 
can  be  entirely  closed  with  a  ligature  or  plugged  with  a  cork 
without  causing  the  individual's  death(Traube,  Lichtheim*). 
It  is  also  knowTn  that  phthisical  patients,  may  live,  though 
the  parenchyma  of  the  lung  be  disintegrated  to  a  high  de- 
gree. Impediments  to  the  pulmonary  circulation  are  sec- 
ondarily associated  with  a  diminution  of  the  respiratory  sur- 
face in  compression  of  the  lung  by  pleuritic  exudation 
(Traubef).  But  Lichtheim'sJ  investigations  show  us  that 
closure  of  the  arterial  circulation  in  the  lungs,  even  three 
quarters  in  quantity,  produces  no  sinking  of  the-  arterial 
pressure.  The  flow  of  blood  to  the  left  heart  suffers  no 
change  because  of  a  compensatory  elevation  of  pressure 
in  the  divisions  of  the  pulmonary  circulation,  which  have 
remained  open,  is  co-incident  with  resulting  increased 
velocity  of  flow  and  extension  of  the  walls  of  the  pulmonary 
artery.  Dangerous  sinking  of  the  aortic  pressure  in  rapid  in- 
crease of  pleural  exudation  is  dependent  upon  direct  compression 
and  displacement  of  the  heart  with  tension  of  some  and  doubli?ig 
of  other  large  vascular  branches.  Bartels  (I.e.)  has  demon- 
strated, post  mortem,  doubling  of  the  inferior  vena  cava  as 
a  result  of  displacement  of  the  heart,  in  exudations  on  the 
left  side.  The  deficient  filling  of  the  aortic  system  further- 
more produces  deficient  nutrition  of  the  heart-muscle  and 
thus  it  is  explained  how  sudden  increase  of  a  pleural 
exudation  can  produce  rapid  death,  by  oedema  of  the  lung 
in  consequence  of  paralysis  of  the  left  ventricle  (Welsch§), 
or  by  sudden  paralysis  of  the  heart  and  syncope. 

Therefore  we  must  operate  when  great  increase  of  volume 

*  Lichtheim,  Versuche  liber  Lungenatelektase.  Archiv.  f.  experimen-. 
telle  Pathologic  Bd.  X. 

f  Traube,  Gesanuss  Beitr£ge  der  Pathologie  und  Physiologic  Bd.  II. 
and  ditto  Symptome  der  Kraukheiten  des  Respirations  und  Circulations 
apparatus.     Berlin,  1867,  p.  94. 

I  Lichtheim,  Die  Storungen  des  Lungenkseislaufee  und  ihr  Einfluss  aui 
den  Blutdruck.  Habilit. — Schrifs.     Breslau,  1876. 

§Welsch,  Fur  Pathologie  des  Lungenodems.  Virchow's  Archiv.  Bd. 
72.  Heft.  3. 


SURGICAL  EMERGENCIES.  1 33 

on  the  affected  side  impedes  respiratory  motions  and  the 
intercostal  spaces  are  strongly  bulged  outwards,  accompa- 
nied by  intense  dyspnoea,  while  the  patient's  face  is  livid 
and  manifests  anxiety.  We  will  operate  not  only  in  cases 
of  direct  imminent  danger  to  life,  but  also  in  the  slower 
cases  where,  though  the  condition  of  the  patient  does  not 
appear  alarming,  and  where  he  is  subject  to  frequent  asth- 
matic attacks,  especially  at  night,  which  may  produce  a  sud- 
den strong  or  great  increase  of  the  exudation,  and  where 
death  often  results   quite  suddenly  (Trosseau*,  Frantzelf). 

2.  We  must  operate  in  circumscribed  purulent  exuda- 
tion (Empyema  necessitatis)  and  then  according  to  the  views 
and  laws  which  apply  to  the  abscesses.  Besides  antiseptic 
precautions,  strictly  followed,  counter-openings,  drainage, 
etc.,  are  employed  to  produce  as  rapid  an  evacuation  of  the 
pus  as  is  possible. 

3.  We  may  operate  even  though  the  effusions  be  not 
directly  threatening,  or  even  when  they  are  of  a  sero- 
fibrinous character,  in  cases  in  which  the  strength  of  the 
organism  is  so  exhausted  that  spontaneous  reabsorption 
cannot  be  expected  soon,  or  even  at  all. 

4.  The  operation  will  be  required  by  large  accumulations 
of  air  in  the  pleura  (pneumothorax).  They  may  be  caused 
(a)  traumatically,  as  after  stabs  or  gun-shot  wounds  ;  sub- 
cutaneously,  but  complicated  with  injuries  to  the  lungs,  as 
in  tearing  the  lung-tissue  after  violent  exertion,  or  severe 
contusion  of  the  thorax,  or  in  open  fractures  of  the  ribs. 
Furthermore  (b),  by  perforation  of  inflammatory  or  necrotic 
foci  in  the  lungs,  through  the  pleura,  as  in  cavities  in 
caseous  pneumonia,  or  in  pulmonary  abscesses,  or  still 
more  frequently  in  pulmonary  mortification.  In  these 
cases  the  question  may  allow  a  circumscribed  progressive 
process  to  the  lung  surface,  or  in  multiple  embolic  foci,  or 
mortification  in  pyaemic  processes,  or  in  caries  auris  int. 
in  ulcerative  endocarditis  or  pylephlebitis.  Pneumothorax 
may  also  be  produced  (<:),  by  the  bursting  of  emphysemat- 
ous pulmonary  alveoli,  by  perforation  of  sharp-pointed 
foreign  bodies  or  ulcers  (especially  cancerous)  from  the 
oesophagus  into  the  posterior  mediastinum,  in  perforation 
of  the  pus  from  degenerated  bronchial  glands  through  the 

*  Trousseau,  Bull,  de  1'academie  de  med.     15  Aoril,  1846. 
f  Frautzel,   Kraukheiten  der  Pleura.   Fiemssens  Handb.  d.  sp.   Path, 
u.  Ther.  Bd.  II.  p.  117. 


134  SURGICAL  EMERGENCIES. 

mediastinum  into  one,  especially  the  left  pleural  space,  and 
at  the  same  time  into  the  bronchi,  or  by  perforation  of 
echinococcus  cysts  (from  the  lung  or  the  liver)  into  the 
pleura  and  synchronously  into  the  stomach  or  intestine. 
Finally  (d),  abscesses  in  the  abdominal  cavity  which  con- 
duct themselves  in  a  similar  manner  can  bring  about  accu- 
mulations of  air  in  the  pleural  spaces.  These,  just  like 
large  accumulations  of  fluid  in  the  pleurae,  can  cause 
threatening  impediments  to  circulation  and  respiration. 
Smaller  accumulations  of  air  are  re-absorbed  spontaneously 
provided  that  some  cause  of  irritation  has  not  entered  with 
it.  In  such  cases  inflammatory,  sero-fibrinous,  purulent  or 
ichorous  exudation  supervenes.  When  there  is  an  accumu- 
lation of  air  in  the  pleura,  under  great  pressure,  re-absorp- 
tion thereof  is  rendered  as  difficult  as  are  fluid  pleural 
exudations  under  high  pressure. 

This  deficient  re-absorption  has  been  attributed  to 
mechanical  closure  of  the  roots  of  the  lymphatic  vessels  by 
direct  pressure  of  the  pleuritic  exudation,  for  which  an 
explanation  has  been  sought  in  the  experiments  of  Dyb- 
kowsky.*  (Frantzel,  I.e.)  Yet  even  Lichtheim  f,  early 
showed  how  paradoxical  this  assumption  is,  by  correctly 
observing  that  pressure  is  employed  in  the  removal  of  fluids 
from  the  cavities,  as,  for  instance,  in  the  larger  joints. 
Lichtheim  questions  curiously  whether  the  pressure  upon 
the  re-absorbing  surface  exerts  its  influence  from  within  or 
without.  It  appears,  according  to  the  experiments  of 
Dybkowsky  (/.  c,  p.  207)  that  the  material  causes  for  the 
lack  of  re-absorption  of  considerable  exudations  into  the 
pleura,  consist  in  an  absence  of  respiratory  movements  of 
the  affected  half  of  the  thorax,  and  secondly,  perhaps,  be- 
cause of  the  surface  stretching  of  the  pleural  membrane. 
The  structure  of  the  basal  tegument  ("  Grundhaut ")  of  the 
pleural  membrane,  the  close  network  of  the  bundles  of  con- 
nective tissue,  which  intercourse  each  other  so  extensively, 
and  through  the  spaces  of  which  the  canals  of  the  lymph 
vessels  penetrate  to  terminate  perpendicularly  upon  free 
pleura  (/.  c,  p.  201)  explain//^?  stretching  of  the  membrane, 
especially  when,  as  under  such  circumstances,  the  network  is  con- 

*  Dybkowsky,  Ueber  Aufsangung  und  Absonderung  der  Pleurawand. 
Aus  der  physiol.  Austaltzu  Leipzig.  Berichte  der  kgl.  Sachs  Gesallschraft 
die  Wissenschr.  zu  Liepzig.  Bd.  XVIII.  1866,  p.  191  ff. 

f  Lichtheim,  Ueber  die  operative  Behandlung  pleuritische  Exsudate 
Volkmanns'  Klin  Vortrage,  No.  43,  p.  16. 


SURGICAL  EMERGENCIES.  1 35 

traded,  and  the  lumina  of  the  lymph  vessels  which  perforate  it  must 
be  closed.  They  run  in  but  one  direction,  perpendicular  to  the 
long  diameter  of  the  intercostal  spaces  in  enlargement  of 
the  thorax.  According  to  this  a  high  pressure,  with  high 
tension  of  the  re-absorbing  membrane,  will  always  produce 
an  impediment,  while  high  pressure,  with  reduced  tension 
(compression  of  the  joints)  would  stimulate  re-absorption 
by  the  lymph  vessels.  Experimental  proof  of  these  ques- 
tions is  urgently  necessary. 

Very  high  tension  will  be  attained  in  pneumothorax,  in 
sub-acute  injuries  to  the  thorax  (ribs  or  lungs)  while  the 
same  would  occur  in  an  open  thorax  wound  only  when  the 
parallelism  between  the  pleura  and  external  wound  is  des- 
troyed. Then  pneumothorax  is  often  associated  with  a 
tensely  drawn  sub-acute  emphysema  of  the  thorax,  and  finally 
of  the  entire  body.  In  sub-acute  injuries  to  the  thorax 
deep  incisions  through  the  soft  parts,  especially  of  the 
thorax,  and  subsequent  forcing  out  the  air  have  often  at- 
tained life-saving  results.*  It  is  not  permissible  to  seek 
for  the  pleural  wound  in  sub-acute  injuries.  When  the 
parallelism  between  the  integumentary  and  pleural  wound 
is  lost  in  complicated  injuries  to  the  thorax,  the  wound  in 
the  skin  may  be  enlarged  over  the  opening  in  the  pleura, 
to  impede  the  further  development  of  the  emphysema  by 
re-establishing  the  communication  between  the  pleural 
space  and  the  air.  Compression  and  subsequent  suture  of 
the  integumentary  wound  must  follow. 

5.  Accumulation  of  blood  or  chyle  in  the  thoracic  space 
(principally  left)  occur  after  bursting  of  the  thoracic  duct 
(chylothorax),  Quincke  f,  or  as  hemothorax  after  burst- 
ing of  an  aortic  aneurism,  following  ulceration  of  the  aortic 
wall,  or  after  haemorrhages  from  venous  vessels  (pulmonary 
veins,  vena  cava  or  varicose  veins  of  the  wall  of  the  pleura). 
Blood  may  also  reach  the  pleural  cavity  through  a  tear  in 
the  walls  of  a  pulmonary  artery,  as  it  courses  through  a 
cavern  in  the  lung,  perforating  the  pleura;  or  when  caries 
of  a  rib  erodes  one  intercostal  artery  or  another.  Pene- 
trating wounds  in  the  thorax  with  contusion  of  the  lung 
are  the  most  frequent  causes  of  accumulations  of  blood  in 
the  thoracic  space.     The  most  rational  procedure  evidently 

*  Koning,  Lehrbuch.  Bd.  I.  p.  612. 

f  Quincke,  Ueber  fetthaltige  Exsudate  Deutsches.  Archiv.  f.  Klin. 
Med.  Bd.  XVI.  p.  121;  contains,  also,  bibliography  on  the  subject. 


136  SURGICAL  EMERGENCIES. 

consists  in  opening  the  pleura  and  removing  the  blood  with 
antiseptic  precautions,  at  the  same  time  directly  arresting 
the  haemorrhage  which,  however,  is  only  rarely  possible 
(pin-compression  of  the  intercostal  arteries,  ligation  of  the 
internal  mammary  artery).  Haemorrhages  into  the  pleura 
are  said  to  remain  fluid  a  long  time  (Pentzoldt*).  Ac- 
cording to  the  experiments  of  Wintrich  (/.  c,  p.  363),  small 
quantities  of  blood  are  entirely  taken  up  by  the  pleura,  even 
though  there  be  air  coincidentally  in  the  thorax.  This 
merits  especial  consideration  in  the  treatment  of  pleural 
perforations,  because  it  permits  us  to  assume  a  conserva- 
tive attitude,  provided  that  the  injury  has  not  occurred 
under  too  unfavorable  circumstances.  We  may  close  the 
wound  by  button  suture,  and  place  the  affected  half  of  the 
thorax  at  rest.  But  if  fever  results,  with  decomposition 
of  the  blood  which  has  been  extravasated  into  the  pleura, 
its  removal  and  subsequent  washing  of  the  pleura  must  not 
be  deferred.  In  haemorrhages  from  the  larger  vessels(aorta), 
therapeutics  are  powerless.  In  case  the  haemorrhage  ceases 
without  death  occurring  from  loss  of  blood,  we  will  pro- 
ceed to  paracentesis,  if  the  extent  of  the  haemorrhage  and 
consequent  pleural  exudation  threaten  life.  In  chylothorax, 
paracentesis  will  be  only  of  transitory  use  and  will  not  im- 
pede the  re-accumulation  of  the  fluid. 

The  means  of  opening  the  thoracic  cavity  to  evacuate  flu- 
ids from  it  are  :  1.  Operation  by  perforation.  2.  By  incis- 
ion. 3.  By  corrosion  of  the  thoracic  wall  (empyeme  en  plus- 
ieurs  temps)  which  now  is  obsolete. 

The  special  indications  for  each  of  these  methods  are  the 
following: 

Perforation  or  puncture  of  the  thorax  must  be  executed 
(a)  in  sero-fibrinous  exudations  and  (b)  in  acute  purulent  exu- 
dations that  are  not  extensive. 

In  accumulations  of  fluids  of  a  sero-fibrinous  consistency 
we  will  have  to  operate  at  any  time  when  threatening  asph- 
yxia occurs.  Secondly,  we  are  entitled  to  puncture,  when 
after  subsidence  of  the  inflammatory'stage  the  mass  of  the 
exudate  appears  so  large  that  spontaneous  re-absorption  of 
the  fluid  can  not  be  expected  (see  above.)  In  both  cases 
the  evacuation  must  be  made  slowly  in  various  postures  and 
with  strict  antiseptic  precautions.     Only  thus  will  we  suc- 

*  Pentzoldt,  Verhalten  von  Blutergussen  in  seroseen  Hohlen.  Deutsches 
Archiv.  f.  Klin.  Med.  Bd.  XVIII.  p.  542. 


SURGICAL  EMERGENCIES.  137 

ceed  in  preventing  inflammatory  manifestations,  in  most 
instances,  as  also  the  danger  of  pyothorax.  The  latter  pro- 
cess is  characterized  by  intense  febrile  motion  or  in  rapid 
cases  by  the  appearance  of  oedema  of  the  soft  parts  on  the  affected 
side  of  the  thorax*  similar  to  those  manifestations  which 
Hippocrates  observed  in  purulent  meningitis.  If,  however, 
antiseptic  precautions  have  been  omitted  or  unsuccessfully 
employed,  and  the  pleural  exudations  approach  suppuration, 
strong  anti-phlogistic  means  will  have  to  be  adopted,  such 
as  application  of  ice,  nitrate  of  potash,  and  saline  purga- 
tives. If  the  exudation  has  become  purulent,  the  second 
indication  for  puncture  of  the  thorax  is  suggested  but  only 
experimentally.  Results  will  be  obtained  only  when  it  is 
possible  to  remove  the  pus  by  simple  puncture  alone  or 
aided  by  antiseptic  washing.  The  fluid  which  is  used  for 
washing  must  finally  run  out  quite  clear  before  the  proce- 
dure may  be  considered  as  concluded.  When  re-accumu- 
lation occurs  the  pleural  cavity  must  be  opened  by  incision 
and  then  drained. 

The  operation  by  incision,  thoracotomy,  must  be  made  in 
general  (a)  when  encapsulated  pleural  abscesses  tend  to 
external  rupture  (empyema  necessitatis).  Furthermore  (b), 
as  we  have  seen  in  Empyemas,  in  which  experimental  punc- 
tures or  aspirations  failed.  Then  (c)  in  all  empyemas  in 
which  there  is  either  direct  danger  of  suffocation  or  where 
there  is  an  intense  fever,  or  after  conclusion  of  the  acute 
stage  a  slow  hectic  fever  (pyaemia  simplex  chronica)  is  devel- 
oped. As  we  will  detail  further  on,  strict  antisepsis  and 
very  free  evacuation  of  the  purulent  pleural  contents  are  the  most 
urgent  requirements  for  success  in  thoracotomy. 

Previous  to  a  detailed  description  of  the  operation  itself, 
the  places  at  which  the  thorax  may  be  opened  must  be  briefly 
mentioned: 

Encapsulated  intra  or  peripleuriticf  exudations  present 
the  bulging  intercostal  space  as  the  site  of  operation;  that  is 
to  say,  we  will  endeavor  to  open  the  cavity  at  a  point  which 
will  insure  the  most  free  evacuation.  In  extensive  free  effu- 
sions into  the  pleural  space  we  must  always  operate  in  the  axil- 
lary line,  remembering  that  the  right  side  may  be  penetra- 
ted less  deeply  than  the  left,  owing  to  the  elevation  of  the 
diaphragm  which  is  there  arched  upwards  by  the  liver. 

*Piorry,  De  la  percussion  mediate,  etc.     Paris,  1828,  p.  85. 
f  Wunderlich,    Ueber  Peripleuritis,   Archiv.   f.   Heilkunde,   1861;  also 
Billroth  v.  Langenbeck  Archiv.  f.  Klin.  Med.  Bd.  XII.  I.  pp.  21-43. 


I38  SURGICAL   EMERGENCIES. 

Thus  Sabatier,  Boyer  and  Pelletan  operated  between  the 
eighth  and  ninth  left  ribs  and  between  the  seventh  and 
eighth  right  ribs,  while  Chopart  and  Desault  entered  more 
deeply  between  the  tenth  and  eleventh  ribs  on  the  left  side 
and  between  the  ninth  and  tenth  ribs  on  the  right.  Evi- 
dently the  guiding  idea  in  these  operations  was  to  seek  the 
lowest  point  of  the  pleural  cavity.  Yet  there  exist  no  satis- 
factory topographical  examinations  of  these  conditions, 
which,  however,  have  lost  much  of  their  importance  through 
the  introduction  of  antiseptic  treatment,  but  are  of  the  great- 
est possible  moment  in  those  cases  in  which  antiseptic  wash- 
ings of  the  cavity  are  to  be  united  to  drainage.  The  recom- 
mendations of  Traube,  Kussmaul,  and  Billroth*  cause  us  to 
select  the  axillary  line  on  both  sides  of  the  fifth  intercostal  sJ>ace,or, 
in  case  of  necessity,  to  limit  ourselves  to  the  space  bounded 
by  the  fourth  and  sixth  ribs.  This  corresponds  to  the  cer- 
tainly rational  advice  given  by  Bardeleben  f  to  fix  the  boun- 
dary line  between  the  abdomen  and  thorax  and  then  to  ope- 
rate 5  cm.  above  that  line  on  the  left  side  and  7  cm.  on 
the  right. 

The  establishment  of  the  boundaries  between  the  abdo- 
men and  thorax  in  the  different  positions  of  the  body,  the 
physical  examination  of  the  lungs  and  the  circulatory  appa- 
ratus, and  above  all  the  course  of  the  febrile  curve,  are  the 
principal  points  which  you  will  need  for  the  appreciation 
of  each  case,  in  forming  a  correct  opinion  of  the  quantity, 
consistency,  and  growth  of  pleural  exudations.  You  must 
never  omit  methodical  attention  to  each  one  of  these  ele- 
ments, so  that  your  operative  procedures  may  not  be  unsafe 
or  perilous  to  the  patient.  Thus,  for  instance,  the  simple 
recognition  of  the  boundaries  between  the  abdomen  and 
thorax  gives  you  no  key  whatever  as  to  the  quantity  of  the 
exudation,  because  though  the  fluid  exerts  an  equal  pressure 
in  all  directions,  the  different  thoracic  walls  are  differently 
elastic  and  consequently  are  expanded  in  different  degrees 
with  corresponding  displacement  of  the  neighboring  or- 
gans. 

As  we  pass  to  a  special  consideration  of  the  modes  of  ope- 
ration we  must  mention  that  puncture  (paracentesis  thora- 
cis) was  always  made  under  efforts  to  exclude  the  air;  thus 

*  Billroth  in  Pitha— Billroth's  Handbuch   d.  Chiv.  Bd.  III.  2.  Abth. 
152  et  sequitur. 
_t  Bardeleben,  Lehrbuch,  etc.  Bd.  III.  p.  633. 


SURGICAL  EMERGENCIES.  1 39 

Henricus  Bassius  (see  Sprengel's  Geschichte  der  Chirur- 
gie)  recommended  drawing  the  skin  so  that  after  the  ope- 
ration it  might  act  as  a  valve,  permitting  the  outflow  but 
impeding  the  entrance  of  air.  Trousseau  (/.  c),  who  wished 
to  operate  according  to  Boyer's  counsel,  between  the  sev- 
enth and  eighth  right  ribs,  made  his  diagonal  incision  at  the 
lower  margin  of  the  eighth  rib,  and  drew  the  wound  to  the 
upper  margin  of  the  same  rib,  where  he  inserted  the  trocar. 
The  trocar  must  always  be  inserted  at  the  upper  margin 
of  the  ribs  because  intercostal  vessels  course  at  their  lower  margins 
or  at  the  upper  boundary  of  each  intercostal  space. 

In  injuries  to  an  intercostal  artery  compresses  have  been 
recommended  which  were  intended  to  press  the  wounded 
arterial  tube  against  the  rib.  A  much  simpler  and  really  effi- 
cacious means  is  to  envelop  the  rib  and  vessel  with  a  cor- 
respondingly thick  antiseptic  thread  on  both  sides  of  the  ar- 
terial wound  by  means  of  which  the  artery  is  pressed  to  the 
rib.  This  procedure  is  also  the  most  reliable  means  in  hem- 
orrhage from  injured  intercostal  veins,  which  may  become 
very  copious  by  the  pumping  action  of  the  motions  of  the 
ribs  (Venous  pumping,  Ludwig  Dybkowsky,  /.  c). 

Puncture  is  made  by  the  trocar,  which  consists  of  a 
canula  provided  with  a  sharp-pointed  polygonal  stylet.  For 
the  purpose  of  impeding  the  possibility  of  the  entrance 
of  air  into  the  pleural  cavity  during  respiratory  movements, 
many  means  and  manipulations  were  devised,  which  were 
quite  important  previous  to  the  antiseptic  period  (use  of 
the  spray). 

First  a  cock  was  provided  for  the  canula.  A  simpler  pro- 
cedure was  suggested,  namely,  that  of  placing  the  finger 
upon  the  opening  of  the  canula  at  each  forced  inspiration. 
Schuh  had  a  small  trough  made,  into  one  of  the  corners  of 
which,  at  its  base,  the  canula  was  inserted,  thus  keeping  it 
ever  beneath  the  upper  level  of  the  evacuated  fluid.  The 
same  principle  guided  Biermer's  proposition  to  insert  the 
opening  of  the  canula  into  a  bottle  over  the  margin  of  which 
the  pleural  fluid  was  to  flow.  Thompson's  and  Frantzel's 
(/.  c.)  T-shaped  trocar  was  constructed  on  a  similar  princi- 
ple. While  the  stylet  can  be  inserted  and  withdrawn  her- 
metically in  the  long  arm  of  the  trocar  the  fluid,  only  after 
the  stylet  is  pushed  back,  can  flow  from  the  forward  part  of 
the  long  arm,  through  the  short  arm,  into  a  vessel,  standing 
on  the  floor,  to  which  it  is  conducted  by  a  long  rubber  tube, 
which  is  fastened  to  the  short  arm.     The  above-mentioned 


140  SURGICAL  EMERGENCIES. 

vessel  is  filled  by  a  certain  (antiseptic)  fluid  and  the  free 
end  of  the  gum  tube  is  continually  maintained  beneath  the 
upper  level  of  this  fluid.  We  have  yet  to  mention  Reybard's 
well-known  proposition,  which  is  not  to  cover  the  canula  with 
the  point  of  the  finger  but  to  stop  it  by  means  of  a  fish  blad- 
der or  a  condom  which  had  been  previously  drawn  over  it, 
so  that  a  part  of  the  bladder  lies  curtain-like  over  the  open- 
ing of  the  canula,  acting  like  a  flap  when  it  is  attracted  by 
reduction  of  pressure  within  the  thorax. 

As  has  been  said,  the  danger  of  entrance  of  air  into  the 
pleural  cavities  through  punctures  has  lost  its  terrors  since 
the  operation  is  made  with  carefully  disinfected  instruments 
and  under  the  protection  of  the  carbolic  spray.  The  result- 
ant simplicity  of  the  procedure  causes  us  to  give  it  decided 
preference  over  aspiration  even  with  such  perfected  appa- 
ratus as  were  constructed  especially  by  Dieulafoy  (/.  c.) 

After  executing  the  puncture  we  must  disinfect  the  skin 
for  a  considerable  extent  around  the  opening,  and  cover  it 
with  an  antiseptic  compress  which  contains  antiseptic 
sponges,  for  the  purpose  of  receiving  the  secretions,  which 
ofttimes  ooze  from  the  wound  in  considerable  quantities. 
After  successfully  puncturing  sero-fibrinous  exudations 
without  re-accumulation  of  the  fluid,  particular  attention 
must  be  directed  to  re-establish  normal  extension  of  the 
lungs,  which  is  brought  about  by  good  feeding  and  vigorous 
exercise  of  the  respiratory  movements  (gymnastics  and 
mounting  hills). 

We  evacuate  purulent  exudations  according  to  the  laws 
which  govern  the  opening  of  abscesses,  and  afterwards  treat 
them  in  the  same  manner.  Antisepsis  is  important,  as  also 
is  complete  and  permanent  evacuation  of  the  pus  and  of  the 
liquids  used  for  washing,  all  of  which  is  accomplished  by 
adequate  drainage.  The  latter  requirements  are  rather 
difficult  of  execution  for  two  reasons  :  first,  as  we  have 
seen,  because  the  most  pendant  point  of  the  pus  cavity  can 
be  established  only  with  difficulty.  On  the  other  hand, 
because  the  thoracic  fistula  contracts  with  great  facility  by 
approximation  of  the  ribs,  which  depends  upon  contraction 
of  the  walls  of  the  inter-thoracic  pus  cavity. 

Hippocrates  recognized  this  unfavorable  occurrence  in 
the  free  evacuation  of  pus.  Therefore  he  recommended 
the  insertion  of  flax  pledgets  into  the  wound  of  thorac- 
otomy. Reybard  preferred  Pare's  direct  trepanation  of  a 
rib,  to  thus  obtain  a  tense,  non-contractile,  thoracic  fistula. 


SURGICAL  EMERGENCIES.  I4I 

We  will  consider  three  procedures,  which  merit  discus- 
sion for  their  efficacy  in  evacuation  of  inter-thoracic  accu- 
mulations of  pus:  first,  the  insertion  of  a  sufficiently  long 
and  amply  wide  drainage-tube  into  the  pleura;  secondly, 
the  production  of  appropriate  counter-openings  for  the 
purpose  of  washing  the  cavity;  and  thirdly,  partial  sub- 
periosteal resection  of  pieces  of  one  or  more  ribs,  whereby 
free  evacuation  is  attained  in  a  most  admirable  manner, 
and  thus  also  a  rapid  contraction  of  the  inter-thoracic  ab- 
scess-cavity. 

The  execution  of  partial  resection  of  ribs  is  very  simple. 
After  splitting  the  soft  parts  and  the  periosteum  on  the  rib, 
the  latter  is  lifted  off  around  the  rib  with  an  elevator,  then 
the  elevator  is  pushed  between  the  rib  and  the  pleural  wall, 
for  the  protection  of  the  latter,  and  the  rib  is  cut  through 
with  a  bone  forceps  or  sawed  with  a  straight  saw.  Then  the 
piece  of  rib  which  has  been  sawn  through  is  lifted  vigor- 
ously out  of  its  periosteal  covering,  and  as  much  of  its 
length  cut  off  with  the  bone  forceps  as  may  be  desired. 
Subperiosteal  excision  permits  avoidance  of  injury  to  the 
intercostal  vessels.  These  are  then  ligated  en  masse,  with 
the  emptied  periosteum  of  the  excised  piece  of  bone  and 
cut  through  between  the  two  ligatures  with  the  inter- 
costal muscles.  Thus  as  large  a  wound  as  may  be  desired 
is  secured  in  the  thoracic  wall  without  any  haemorrhage 
whatever. 

During  execution  of  resection  of  the  ribs  we  may  wash 
out  the  pleural  cavity  with  antiseptics.  Pirogoff  recom- 
mended a  one  to  two-per-cent  aqueous  solution  of  tincture 
of  iodine  for  this  purpose.  Diluted  carbolic  acid  (10  to 
20  per  1000)  has  been  successfully  employed;  but  in  chil- 
dren, or  where  carbolic  poisoning  supervenes,  it  may  be 
substituted  by  salicylic  acid  (1  to  500)  or  solutions  of  thymol 
(1  to  1000)  or  solutions  of  hypermanganate  of  potash  (1  to 
500)  or  even  by  one-half-per-cent  solutions  of  common  salt 
(Frantzel,  /.  c,  p.  149).  Great  importance  must  be  attached 
not  only  to  expulsion  of  the  pleural  contents,  but  also  to 
most  rapid  and  complete  evacuation  of  the  liquid  used  for 
washing  immediately  thereafter;  this  applies  especially  to 
carbolic  solutions. 

The  after-treatment  subsequent  to  the  establishment  of  a  thoracic 
fistula  must  be  directed  especially  to  good  nutrition.  The 
evacuation  of  the  masses  of  pus  which  have  accumulated 
under  high  pressure  in  the  pleural  cavity,  as  well  as  care 


142  SURGICAL  EMERGENCIES. 

directed  to  the  prevention  of  a  re-accumulation  or  reten- 
tion of  pus,  will  contribute  most  rapidly  to  an  elevation  of 
the  patient's  strength,  as  then  the  absorption  of  septic  py- 
rogenous  matters  will  be  reduced  to  a  minimum.  The  fever 
will  fall,  and  with  its  fall  there  will  be  a  relief  of  disturbed 
nutrition  and  assimilation  which  were  maintained  coinci- 
dent with  increased  destruction  of  albumen.  To  completely 
cure  the  inter-thoracic  cavity,  rest  and  residence  in  a  mild 
climate  will  be  required,  besides  the  appliances  for  the 
evacuation  of  pus,  which  have  been  discussed.  The  more 
favorable  the  auspices  under  which  all  of  these  conditions  are 
united,  the  sooner  the  thoracic  fistula  can  be  cured,  which,  it 
is  true,  often  taxes  the  patience  of  the  sufferer,  as  well  as  that 
of  the  physician.  It  occurs,  in  case  purulent  pleuritis  was 
not  developed  in  a  tuberculous  constitution,  or  in  case  secon- 
dary tubercles  were  not  developed.  In  some  cases  we  will 
be  justified  in  stimulating  the  cicatrization  of  the  cavity  by 
scarification,  when  the  contraction  of  the  inter-thoracic 
space  arrives  at  a  standstill. 

When  the  thoracic  fistula  is  cured,  and  the  contraction 
of  the  granulations  draw  the  lung,which  had  been  collapsed, 
again  to  the  thoracic  wall,  and  the  lung-tissue  has  again 
become  elastic  (Billroth,  /.  c,  p.  156),  respiratory  exercises 
may  be  employed  to  re-extend  the  lung. 

Accumulations  of  fluids  and  air  in  the  pericardium  will  re- 
quire operative  procedures  much  more  rarely,  although 
when  they  exercise  great  tension  they  may  materially  dis- 
turb the  action  of  the  heart.  This  applies  especially  to 
haemorrhages  into  the  pericardium,  as  in  spontaneous  rup- 
tures of  the  heart  or  more  frequently  in  traumatisms  of  the 
heart,  as  in  injuries  by  stabs  or  gun-shot.  Dropsical  effu- 
sions into  the  heart-sac  occur  in  affections  of  the  kidneys, 
but  mostly  with  accumulations  of  fluid  in  the  pleurae.  If 
the  effusion  is  rapid,  or  if  re-absorption  of  a  chronic  in- 
flammatory exudation  is  made  impossible,  by  changes  in 
the  serous  membrane,  the  increased  pressure  on  the  con- 
tents of  the  pericardium  may  produce  disturbances  of  the 
circulation  and,  secondarily,  of  respiration  as  well.  Anxiety 
and  oppression,  dull  pressure  and  a  sensation  of  weight  in 
the  cardiac  region,  are  the  symptoms  which  are  aggravated 
by  motion,  as  well  as  the  dorsal  decubitis.  The  heart's 
action  is  irregular,  arythmic,  sometimes  small  and  faint,  at 
other  times  tumultuous  and  violent.  Extensive  filling  of 
the  heart-sac  is  said  to  produce  a  bulging  from  the  third 


SURGICAL  EMERGENCIES.  143 

to  the  fifth  rib;  occasionally,  also,  a  kind  of  fluctuation  is 
felt. 

Evacuation  of  pericardial  effusions  is  permissible  only 
when  physical  diagnosis  establishes  the  effusion  and  its  ex- 
tent. Dieffenbach  (Oper.  Chirurgie,  Bd.  II.  p.  397)  advo- 
cates Karawjew's  procedure  for  large  effusions,  viz.,  the 
insertion  of  a  trocar  between  the  fifth  and  sixth  ribs  at  a 
point  distant  three  fingers'-breadth  left  of  the  left  margin 
of  the  sternum  through  the  intercostal  space  into  the  peri- 
cardium. Roger*  bespeaks  favor  for  the  application  of 
small  capillary  trocars,  and  unites  Dieulafoy's  aspiration 
with  puncture.  Roger  prefers  the  fifth  intercostal  space 
as  the  site  of  election,  and  makes  the  puncture  in  the  para- 
sternal line  or  beyond  it,  according  to  the  point  of  the  im- 
pulse of  the  apex.  The  trocar,  then,  should  not  be  sunk 
perpendicularly  upon  the  heart's  surface,  but,  as  much  as 
possible  parallel  to  it;  thus  backwards  and  towards  the 
mesian  line.  Skjelderup'sf  method  is  much  more  rational, 
because  it  facilitates  a  view  of  the  parts.  He  recommended 
trepanning  the  sternum  between  the  fifth  and  sixth  ribs,  at 
the  union  of  the  cartilage  of  the  fifth  rib  with  the  sternum, 
and  thus  to  expose  the  heart-sack,  which  then  may  be 
opened  by  the  knife  or  trocar  with  complete  safety.  This 
procedure  is  only  apparently  more  injurious  than  direct 
puncture  of  the  pericardium.  Yet  this  circumstance  merits 
less  consideration,  since  we  do  not  perform  any  such  ope- 
rations without  antiseptic  precautions.  Isolated  cases  of 
the  puncture  of  pericardiac  exudations  which  saved  life, 
temporarily  at  least,  and  in  which  large  qnantities  of  fluids 
were  evacuated,  may,  perhaps,  admit  the  explanation  that 
the  relief  was  as  much  owing  to  the  coincident  opening  of 
the  left  pleura  and  evacuation  of  fluid  therefrom. 

If  the  accumulation  of  fluid  in  the  heart  is  based  upon 
tuberculosis,  or  if  acute  pericarditis  is  only  an  accompani- 
ment to  infectious  endo-carditis  or  myocarditas  (as  in  ty- 
phus, acute  articular  rheumatism,  etc.)  or  dependent  on  a 
traumatic  inflammation  of  the  heart-muscle,  then  puncture 
will  accomplish  but  little. 

Purulent  exudations  in  the  heart-sac  but  seldom  assume 
great  proportions,  and  are  found  as  concomitants  to  and 


*  Roger,  Bull,  de  l'acad.  de  Wed  1875,  Nos.  42  and  43. 
f  Skjelderup,  Acta  nova  societatas  med.  Hafriensis.  T.  I.  Hafu.  1818, 
p.  280. 


144  SURGICAL  EMERGENCIES. 

dependents  upon  the  general  condition  when  post-mortem 
examinations  are  made  of  those  dead  of  sepsis,  puerperal 
fever,  or  infectious  osteomyelitis. 

Accumulations  of  blood  are  found  in  contusions  of  the  heart, 
most  especially  after  direct  injuries.  In  the  latter  cases 
pneumopericardium  may  also  result.  But  accumulations 
of  air  in  the  heart-sac  have  been  found  after  adhesions 
of  it  with  the  diaphragm  and  the  perforation  of  a  gastric 
ulcer  through  the  diaphragm  into  the  heart-sac  (Rosen- 
stirn's  case*). 

Not  all  injuries  to  the  heart  are  fatal.  Perforations  of 
the  heart  have  often  healed,  and  cases  are  recorded  where 
bullets  were  found  encapsulated  in  the  heart-muscle.  Bul- 
lets may  also  lie  for  a  long  time  within  a  cavity  of  the  heart 
without  producing  any  disturbances,  as  can  be  proven  by 
the  introduction  of  foreign  bodies  (glass  balls,  little  glass 
tubes,  etc.)  into  the  right  heart,  through  the  jugular  vein,  as 
is  done  experimentally.  In  stabs  into  the  heart,  fatal  haem- 
orrhage is  prevented,  when  the  penetration  has  been  deep, 
by  closing  the  wound  through  muscular  action,  or  through 
the  establishment  of  a  valve-like  mechanism.  Wounds 
into  the  heart  have  healed  by  cicatrization  where  the  scar 
could  become  adherent  to  the  heart-sac.  Small  accumu- 
lations of  blood  or  air  in  the  pericardium  are  re-absorbed, 
as  we  have  detailed  in  considering  these  occurrences  in 
the  pleura.  Recent  injuries  to  the  heart,  especially  stabs, 
may  be  best  closed  by  suture,  while  gun-shot  wounds  to 
the  heart  may  be  closed  by  antiseptic  compresses,  besides 
which,  as  is  self-evident,  absolute  rest  and  venesection  are 
required.  Digital  exploration  of  the  wound  is  indicated 
only  when  the  perforating  instrument  is  broken  off  in  the 
wound,  and  could  not  have  been  extracted  by  the  witnesses 
to  the  inju^r  or  by  the  wounded  person  himself.  It  must 
be  done  only  when  the  foreign  body  can  be  easily  reached. 
Projectiles  must  not  be  sought  for  in  injuries  to  the  heart. 
Pare's  dictum,  "  Je  le  pansais;  Dieu  l'a  gueri"  holds  good  to- 
day, owing  to  the  uncertainty  of  their  diagnosis.  Acu- 
puncture and  electro-puncture  of  the  heart,  as  have  been 
recommended  in  paralysis  of  the  heart,  to  stimulate  it  to 
action,  as  all  intentional  punctures  to  the  heart,  are  repre- 
hensible. 


*  Timmers,  Pneumopericardium,  Academisch.  Proefschrift.     Leiden 
1879. 


SURGICAL  EMERGENCIES.  14$ 

Electro-puncture  is  reprehensible  because  weak  currents 
cannot  stimulate  the  heart-muscle,  while  strong  currents 
may  definitely  paralyze  it.  Acu-puncture,  to  develop  me- 
chanical heart-beats,  is  reprehensible  because  its  result  is 
uncertain,  and  because  fatal  injuries  to  the  coronary  arteries 
of  the  heart  may  result  (verbal  communication  of  a  post- 
mortem examination  in  Breslau  by  Prof.  Weigert).  Instead 
of  acu-puncture,  mechanical  kneadings  of  the  heart  through 
the  thoracic  walls  are  recommendable,  as  we  mentioned  in 
auto-transfusion  (Bohni*).  Frequently  the  success  of  the 
so-called  artificial  respiration  of  Marshall  Hall  are  to  be 
attributed  to  it  alone,  especially  in  chloroform  asphyxia,  in 
which  the  increased  flow  of  blood  to  the  heart  is  furthered 
by  the  forced  thoracic  movements. 

*Bohm,  Centralbl,  f.  med.  Wiss<?nsehapten  (1874)  No.  21. 


146  SURGICAL  EMERGENCIES. 


LECTURE   XI. 

II.  Free  and  cystic  accumulations  of  fluids  and  swell- 
ings FROM  RETENTIONS  IN  THE  ABDOMINAL  CAVITY. Indi- 
cations for  puncture  in  Ascites. — Sites  of  puncture. — Oper- 
ative procedures. — Differential  diagnosis  from  ovarian  tumors. 
— Accumalations  of  air  in  the  abdominal  cavity  and  intestines. 
— Echinococcus  cysts. — In  the  liver. — Modes  of  treatment. 
— Hydronephrosis.  — Etiology  and  treatment. — Cysts  of  the 
ovaries. — Pu7ictures  and  their  consequences. —Solid  abdo- 
minal  TUMORS. 

Cyst  otomy. — Indications. — Posterior  catheterism. —  For- 
eign bodies  in  the  urethra. —  Their  extraction. — Procedures  in 
cystotomy.     Injuries  to  the  bladder. 

H.EMATOMETRA. — Hydrometra. 

III.  Perilous  contraction  of  the  cranial  space  (see 
below). 

We  must  distinguish  accumulations  of  fluids  within  the 
abdomen  which  occur  either  free  in  the  abdominal  cavity 
(Ascites),  or  which  are  found  within  pathological  cystic 
spaces  (echinococci,  hydronephrotic  sacs,  ovarian  cysts), 
or  finally  such  as  lead  to  the  development  of  tumors  of 
retention  within  hollow  organs. 

Free  accumulations  of  fluids  within  the  abdominal  cavity 
occur  : 

1.  In  chronic  inflammation  of  the  peritoneum  (peritonitis 
chronica  tuberculosa).  If  during  this  process  extensive  ad- 
hesions have  been  formed,  the  fluid  may  accumulate  and 
be  encysted  in  one  part  of  the  abdominal  cavity,  which 
condition  requires  differentiation  from  cystic  intra-abdomi- 
nal tumors  when  an  operation  is  to  be  performed. 

2.  In  general  hydraemia,  such  as  occurs  in  prolonged 
suppurations,  in  amyloid  changes  in  the  organs,  in  the 
syphilitic  cachexia,  etc. 

3.  In  abnormal  secretion  of  the  urine  in  the  course  of 
chronic  nephritis. 

4.  In  consequence  of  engorgement  of  the  portal  circula- 
tion in  diseases  of  the  liver  or  of  the  heart. 


SURGICAL   EMERGENCIES.  147 

5.  In  tumors  of  the  peritoneum,  and  tumors  which  com- 
press the  portal  radicle  ;  furthermore,  as  complications  of 
ovarian  tumors  ascites  presents  itself  in  the  train  of  the 
inflammatory  changes  which  occur  in  the  peritoneum,  or  as 
one  of  the  consequences  of  the  development  of  a  cachexia. 

In  simple  inflammatory  processes  affecting  the  peri- 
toneum, the  fluid  contents  of  the  abdominal  cavity  appear 
clear  as  water,  sometimes  with  a  slight  yellowish  or  green- 
ish tinge.  Occasionally  we  find  flakes  of  fibrine,  which  are 
formed  in  the  fluid  or  develop  after  the  extracted  fluid  has 
stood.  It  also  contains  albumen,  which  is  precipitable  by 
boiling,  but  no  paralbumin  is  found.  The  fluid  does  not 
coagulate  in  toto,  nor  does  it  contain  fat  (see  the  accumula- 
tions of  chyle  and  so-called  hydrops  adiposus  in  the  abdo- 
men, Quincke,*  /.  c.)  Cylindrical  epithelium  and  cholesterin 
are  not  found  in  these  cases,  which  distinguishes  them  from 
ovarian  cysts  (Waldeyer,  Spiegelberg  |). 

The  indications  for  the  evacuation  of  the  fluids  which 
have  accumulated  in  the  abdomen  are  : 

a.  Impediments  to  respiration,  which  result  from  the 
diaphragm  being  crowded  against  the  thoracic  cavity  and 
thus  a  high  degree  of  dyspnoea  is  developed. 

b.  In  violent  pains  which  are  produced  by  pressure  upon 
the  sacral  plexus  or  the  solar  plexus,  and 

c.  When  the  accumulation  of  fluid  exercises  a  com- 
pression upon  the  vena  cava,  with  oedema  of  the  lower 
extremities. 

1.  The  places  through  which  fluids  maybe  evacuated  from 
the  abdomen  are  very  numerous.  Formerly  the  abdomen 
was  punctured  through  the  navel,  as  was  recommended  by 
Hippocrates  and  Celsus,  until  Dieffenbach  proved  the  im- 
propriety of  puncturing  this  site,  firstly,  because  the  wound 
heals  up  slowly,  and,  secondly,  because  of  the  secondary 
inflammations  which  easily  supervene  at  this  site. 

2.  The  second  point  for  puncture  lies  in  the  abdomen  be- 
tween the  navel  and  the  symphysis.  It  has  been  accredited 
to  Paul  of  ^Egina,  and  is  the  method  which  is  preferred  in 
England. 

*  Quincke,  Ueber  fetthaltige  Transsudate.  Deutsch.  Arch.  f.  klin. 
Medicin.  Bd.  16.,  p.  128.  (Chylous  dropsy  from  bursting  of  chyle  vessels 
and  adipose  dropsy  from  admixture  of  fatty  degenerated  endothelium 
to  the  serum,  or  of  fatty  tumor  cells  to  the  ascites-fluid,  as  in  carcinosis 
peritonei). 

\  Spiegelberg,  Volkmann's  klin.  Vortrage.     No.  55. 


I48  SURGICAL   EMERGENCIES. 

• 

3.  Half  way  on  a  line  between  the  navel  and  the  anterior 
superior  spine  of  the  ileum  on  the  left  side,  in  enlargement 
of  the  liver,  and  on  the  right  side  in  hypertrophy  of  the 
spleen  (for  instance,  after  intermittents).  This  method  was 
preferred  in  France  and  Germany,  and  was  recommended 
by  Palfyn  and  Monro. 

4.  At  the  intersection  of  two  lines,  one  of  which  envelops 
the  abdomen  horizontally  from  the  navel  to  the  spinal 
column  and  the  other  drawn  perpendicular  to  it,  from  the 
free  margin  of  the  ribs  to  the  anterior  superior  spine  of  the 
ileum. 

5.  In  the  left  hypochondrium  close  below  the  last  ribs 
(Scarpa),  as  in  the  ascites  of  pregnancy,  or  in  large  tumors 
in  the  hypogastric  region.  Abortion  often  follows  punc- 
ture. 

6.  In  the  scrotum  (Ledran),  when  there  is  a  hernial  sac 
communicating  with  the  abdominal  cavity;  then  the  site  of 
puncture  is  the  deepest  point  of  the  cavity  which  contains 
the  fluid. 

7.  Through  the  vagina  (Henkel),  or  through  the  rectum 
(Malacarne).  The  two  latter  points  of  puncture  were 
selected  because  of  the  guiding  idea,  that  as  they  were  the 
most  pendent,  they  would  best  allow  the  complete  outflow 
of  the  fluid.  Both  of  these  sites,  however,  appear  disad- 
vantageous because  they  may  easily  develop  ichorous  pro- 
cesses, which  may  extend  to  the  peritoneum. 

Previous  to  evacuating  such  fluids  as  may  lie  free  in  the 
abdominal  cavity,  we  must  employ  exact  percussion  of  the 
abdomen  while  sitting  and  lying,  and  on  the  side,  to  estab- 
lish the  position  and  the  relations  of  the  intestines  to  the 
fluid,  so  as  to  avoid  injury  to  the  intestine. 

When  the  site  of  puncture  is  determined  upon,  the  patient 
is  placed  in  a  half-sitting  posture  and  after  again  establish- 
ing the  boundaries  between  gut  and  fluid  by  careful  per- 
cussion, a  small  incision  is  made  at  the  site  of  puncture. 
This  incision  should  run  parallel  to  the  axis  of  the  body 
and  should  penetrate  the  skin,  which  is  frequently  quite 
cedematous.  The  trocar,  being  held  in  the  closed  hand,  is 
forced  through  the  wound  in  the  skin  by  a  stout  push,  not 
in  a  boring  or  screwing  manner.  Thus,  with  one  smart  im- 
pulse, it  is  inserted  into  the  abdominal  cavity.  The 
abdomen  of  the  patient  is  covered  above  and  below  the 
site  of  puncture  by  long  towels,  which  envelop  the  body 
and  have  their  ends  crossed  upon  the  patient's  back,  where 


SURGICAL  EMERGENCIES.  I49 

the}r  are  drawn  more  and  more  tightly  together  as  the  fluid 
escapes,  for  the  purpose  of  reducing  the  volume  of  the 
abdominal  cavity. 

It  were  well  in  direct  puncture,  as  when  a  preliminary 
incision  in  the  skin  is  made,  to  avoid  parallelism  between 
the  wound  in  the  skin  and  that  in  the  abdominal  muscles 
by  displacing  the  former  previous  to  the  puncture. 

Strict  observance  of  antiseptic  rules  is  absolutely  requi- 
site to  insure  against  the  apearance  of  inflammatory  mani- 
festations after  the  puncture  of  ascites.  The  evacuation 
of  the  fluid  should  take  place  beneath  an  antiseptic  solution. 
The  same  idea  governs  the  use  of  instruments  for  aspira- 
tion, by  which  the  fluid  from  the  abdominal  cavity  is 
sucked  into  a  disinfected  vacuum  (Traube,  Pean).  Further- 
more, the  fluid  must  be  evacuated  slowly,  with  increasing 
compression  of  the  abdominal  walls,  to  avoid  tearing  of  the 
intra-abdominal  vessels, which  might  result  from  the  sudden 
relief  from  pressure.  If  the  canula  becomes  plugged,  as  it 
may,  by  flakes  of  fibrine,  the  canal  may  be  freed  by  corres- 
pondingly thick,  bent  plugs  of  metal.  When  it  is  decided 
to  conclude  the  operation,  the  canula  is  rapidly  extracted 
and  a  closely  fitting  bandage  is  applied.  The  bandage 
contains  antiseptic  sponges  for  the  purpose  of  compression. 
The  application  of  the  spray  in  this  instance,  as  in  all 
punctures  of  the  cavities  (thorax,  abdomen,  joints),  or 
pathological  cysts,  is  highly  recommendable.  After  the 
operation  complete  rest  is  requisite.  Formerly  the  injec- 
tion of  solutions  of  iodine  into  the  abdomen  was  recom- 
mended (Leriche,  Ore,  Boinet). 

When  encapsulated  fluids  in  the  abdominal  cavity  are  to 
be  treated,  the  possibility  of  confounding  them  with  ovarian 
tumors  must  be  considered.  Careful  palpation  and  per- 
cussion of  the  abdomen,  and  combined  examination  per 
rectum  and  per  vaginam,  as  well  as  chemical  and  micro- 
scopic examination  of  the  fluid  obtained  by  an  exploratory 
puncture,  will  facilitate  differential  diagnosis  (compare  the 
special  treatises  of  Spencer  Wells,  Spiegelberg,  Olshausen). 
Palpatory  examination  immediately  after  evacuating  the 
fluid  should  not  be  omitted.  Still,  errors  in  diagnosis  have 
been  made,  even  by  experienced  specialists,  but  they  in  all 
probability  will  occur  less  frequently  in  the  future,  because 
simple  exploratory  puncture  will  be  substituted  by  an  ex- 
ploratory incision  of  the  abdomen  under  antiseptic  precau- 
tions. 


i$0  SURGICAL  EMERGENCIES. 

Accumulations  of  air  in  the  abdominal  cavity  (tympanites 
peritonealis)  occur  principally  after  the  escape  of  intestinal 
gases  in  perforation  of  the  intestines,  but  more  rarely  after 
perforation  of  a  pulmonary  abscess  into  the  peritoneum, 
which,  of  course,  must  be  preceded  by  coalition  of  the 
lungs  with  the  diaphragm.  Puncture  may  be  made  in 
cases  where  sudden  diffuse  septic  peritonitis  has  asserted 
itself,  for  the  purpose  of  obtaining  relief  to  respiration  ;  as 
a  life-saving  means  it  would  be  valueless.  Konig  (Handb. 
II.,  Theil.  p.  50)  raises  the  question  whether  such  desperate 
cases  would  not  preferably  require  opening  the  abdominal 
cavity  by  incision,  perhaps  at  two  places,  with  subsequent 
disinfecting  irrigation. 

Puncture  in  intestinal  tympanitis  (recommended  by  Mothe) 
promises  only  subjective  alleviation  to  the  patient.  Very 
fine  trocars  must  be  employed  to  avoid  the  escape  of  intes- 
tinal contents  into  the  abdominal  cavity.  Interference  in 
these  cases  can  have  a  life-saving  object  only  when  it  is  di- 
rected against  the  primary  cause  of  the  accumulation  of 
gas,  that  is,  in  hernial  strangulation,  or  in  intra-abdominal 
closure  of  an  intestinal  tube,  etc. 

Cysts  of  echinococcus,  especially  in  the  liver,  have  as  yet 
been  treated  in  a  great  variety  of  ways.  When  they  grow 
rapidly  they  cause  difficulties  similar  to  those  produced  by 
free  ascites. 

The  oldest  method,  and  that  which  is  used  almost  exclu- 
sively in  Iceland  (one  of  the  principal  homes  of  the  devel- 
opment of  echinococcus)  is  cauterization,  most  frequently 
with  the  paste  of  chloride  of  zinc  or  caustic  potash  (Reca- 
mier,  Finsen*).  This  method  is  very  painful  and  tedious, 
as  the  eschar  allows  the  parasitic  cyst  to  open  only  after  the 
lapse  of  weeks. 

The  second  method  is  simple  puncture  of  the  echinococ- 
cus cyst,  with  or  without  injection  of  solutions  of  iodine. 
Contraction  of  the  cyst  and  death  of  the  parasite  has  been 
observed  frequently  after  simple  puncture.  A  contraindi- 
cation to  simple  puncture  consists  in  that  it  occasionally 
allows  the  fluid  to  escape  from  the  opened  echinococcus 
sac  into  the  abdominal  cavity.  In  the  most  unfavorable 
cases,  when  the  echinococcus  fluid  escapes  clear  and  unde- 
composed,   there   results  a  distribution  of  entozoic  germs 

*  Finsen,  Bidrag  til  Kundsgab  om  de  i  Island  endemiske  Echinokoker. 
Ugeskrift  for  Laeger.     Raidke,  3.  Bd.  III.  No.  5,  8. 


SURGICAL  EMERGENCIES.  I5l 

into  the  abdominal  cavity  as  in  spontaneous  bursting  of 
echinococcus  sacs.  If  the  fluid  contains  pus  diffuse  septic 
peritonitis  will  result. 

Therefore  if  it  is  decided  to  evacuate  the  contents  of  a 
cyst  by  puncture,  Simon's*  method  of  double  punc- 
ture deserves  preference.  It  entails,  previous  to  opening 
the  cyst,  the  production  of  adhesions  between  the  cyst- wall 
(surface  of  liver)  and  the  abdominal  parietes.  Then  two 
long,  thin  exploratory  trocars  are  thrust  into  the  cyst. 
Their  stylets  are  removed,  and  after  the  evacuation  of  a  cer- 
tain quantity  of  the  fluid  the  openings  in  the  canula  are 
plugged  with  carbolized  wax.  The  canulae  are  allowed  to 
remain  as  long  as  eight  days,  continuously  covered  with  an- 
tiseptic dressing.  The  object  desired  to  be  obtained  by 
this  is  the  formation  of  adhesions  around  the  sites  of  punc- 
ture. When  it  is  decided  that  the  adhesions  are  sufficiently 
firm  and  extended,  the  abdominal  coverings  are  carefully 
incised  between  the  canulae  down  to  the  walls  of  the  cysts 
and  then  the  latter  is  opened  by  a  broad  incision. 

The  formation  of  adhesions  under  rigorous  antiseptic 
precautions  was  achieved  by  Volkmann,f  following  the  ex- 
ample of  Begin,  for  opening  abscesses  of  the  liver,  and  that 
of  Costallat  for  colotomy  or  for  enterotomy.  He  slit  the 
abdominal  coverings  directly  to  the  surface  of  the  liver  or 
the  echinococcus  sac,  and  after  filling  the  slit  in  the  ab- 
dominal wall  with  pressed  Lister's  gauze  (Kriillgaze)  he 
covered  all  with  an  antiseptic  compress.  The  antiseptic 
dressing,  which  had  been  pressed  in,  acts  similarly  as  does 
the  introduction  of  the  trocar-canulae  in  Simon's  method. 
When  the  adhesions  are  sufficiently  resistent,  the  incision 
into  the  cyst  is  made  and  then  the  cavity  is  washed  out  with 
antiseptic  solutions  previous  to  the  introduction  of  a  suffi- 
ciently wide  drainage-tube,  which  will  eventually  permit  the 
passage  of  even  larger  secondary  vesicles. 

Konig  (/.  c,  p.  59)  considers  it  safer  not  to  open  the  perito- 
neum immediately,  but  at  first  to  split  the  abdominal  cov- 
erings only  and  to  defer  the  peritoneal  incision  to  the  sec- 


*  Simon,  Deutsche  Klinik.  1866,  p.  388,  404,  416.  See  also,  Robert 
Busch,  Einige  Fiille  von  Echinococcus  hepatis  Inaug.-Diss.  Rostock 
1864.  Furthermore:  Uterhart,  Berliner  Klinische  Wochenschrift,  1868, 
No.  14,  16,  and  17. 

f  Ranke,  Verh.  d<*s  VI.  Congr.  d.  deutschen  Ges.  f.  Chir.  Grossere 
Vortrage,  p.  54. 


152  SURGICAL  EMERGENCIES. 

ond  seance,  when  he  cuts  it  with  the  superficial  layers  of 
the  liver,  or  the  cyst  itself. 

The  treatment  of  Hydronephrosis  has  been  admitted  to  the 
domain  of  operative  surgery  only  since  the  introduction  of 
the  antiseptic  treatment  of  wounds.  Hydronephroses  owe 
their  development  to  urinary  engorgement  such  as  occur 
in  the  formation  of  calculi  in  the  pelvis  of  the  kidney.  A 
further  cause  of  this  engorgement  has  been  attributed 
to  valves  at  the  ostium  pelvicum  of  the  ureters,  which 
valves  are  either  congenital  ( Wulfler,*  Englisch)  or  formed 
secondarily  (Baum,  Simon). 

Previous  to  proceeding  to  operative  treatment  it  is  im- 
portant that  we  elicit  the  functional  capacity  of  the  other 
kidney  by  determination  of  the  solid  constituents  of  the 
urine.  When  the  contents  of  the  hydronephrotic  sac  are 
clear  and  undecomposed,  and  when  the  tumor  is  not  very 
great,  it  may  be  punctured  and  iodine  solutions  injected 
into  it.  In  pyonephroses  double  puncture  has  been  sug- 
gested, as  inechinococci  of  the  liver. 

In  isolated  cases  the  abdomen  was  opened  immediately 
after  previous  puncture  and  efforts  were  made  to  extirpate 
the  cystic  sac,  or,  when  this  proved  inexecutable,  at  least 
to  obliterate  it  by  splitting  the  sac  and  sewing  the  cyst 
wall  into  the  abdominal  wound  and  subsequent  drainage 
-was  established.  Echinococci  of  the  kidneys  (as  also  of 
the  spleen,  omentum  of  the  Cavum  Douglasii,  etc.)  must  be 
treated  according  to  the  principles  that  have  been  laid  down 
in  the  treatment  of  Echinococci  of  the  liver. 

In  reference  to  ovarian  cysts,  the  treatment  of  which  can 
not  be  detailed  here,  we  will  but  cite  that  their  puncture 
must  be  executed  only  in  direct  danger  to  life,  that  is,  in  the 
occurrence  of  high  degrees  of  dyspnoea,  compression  of  the 
vena  cava,  with  oedema  of  the  lower  extremities,  anuria, 
symptoms  of  incarceration,  ileus,  danger  of  rupture  of  the 
cyst,  with  coincident  pregnancy.  After  removal  of  the 
danger  to  life,  ovariotomy  should  be  performed  as  soon  as 
possible.  Puncture  of  unilocular  cysts  (dropsy  of  the  ova- 
rian follicle  and  parovarian  cysts)  has  succeeded  in  pro- 
ducing a  radical  cure  in  isolated  cases  only  (Schatzf).  In 
multilocular  ovarian  tumors,  puncture  of  the  swelling  is  to 

*  Wolfler,  Neue  Beitrage  zur  chirurg.  Pathol,  d.  Nieren,  von  Langen- 
beck's  Archiv.     1877.     Bd.  XXI.  Heft  4. 
f  Schatz,  Archiv  f.  Gynakologie.     Bd.  IX,  p.  128. 


SURGICAL  EMERGENCIES.  1 53 

be  executed  only,  omitting  the  question  of  direct  danger 
to  life,  for  diagnostic  purposes,  previous  to  operation,  or  for 
reduction  of  the  tumor  during  the  operation.  Pregnant 
women,  in  most  instances,  bear  palliative  punctures  of  ova- 
rian cysts  without  functional  disturbances. 

As  in  the  treatment  of  ovarian  tumors,  so  also  in  rapidly 
growing  solid  tumors  in  the  abdominal  cavity  (tumors  of  the 
uterus,  of  the  omentum,  of  the  spleen,  etc.)  also  in  ruptures 
of  the  uterus  with  extrusion  of  the  child  into  the  abdomi- 
nal cavity,  opening  the  abdomen  (laparotomy)  is  to  be 
made  whether  it  be  only  for  diagnostic  purposes  (exploratory 
incision)  or  for  the  total  removal  of  foreign  bodies  (tumors, 
foetus  with  placenta,  etc.).  If  the  rapid  increase  of  volume 
of  the  tumors  produces  functional  disturbances  as  in  ovarian 
tumors,  their  removal  must  be  added  to  the  procedures 
which  are  considered  among  those  for  direct  life-saving. 

Cystotomy  (punctio  vesicae)  serves  for  evacuating  the 
urine  from  the  bladder  in  cases  in  which  the  natural  way  is 
interrupted  in  any  manner.  Formerly  cystotomy  was  made 
more  frequently.  It  was  employed  in  every  urethral  con- 
traction when  the  introduction  of  a  catheter  was  not  im- 
mediately successful.  Now  owing  to  the  perfection  of 
catheterism,  as  also  owing  to  the  progress  in  the  treatment 
of  strictures  of  the  urethra,  only  the  following  indications 
for  cystotomy  remain: 

1.  Sudden  retention  of  urine,  with  danger  of  rupture  of 
the  bladder  in  inflammatory  swelling  of  the  prostate,  as  for 
instance,  when  false  passages  have  been  made  in  it,  or  in  its 
surroundings,  by  the  catheter.  In  acute  retention  after 
contusions  of  the  urethra  we  will  proceed  to  relief  of  the 
difficulty  by  cystotomy,  when  we  find  it  impossible  to  intro- 
duce a  permanent  cathether,  after  splitting  the  injured 
urethra  through  the  perineum.  In  such  cases  in  which  the 
central  part  of  the  urethra  is  not  discoverable,  R.  Volk- 
mann*  employed  posterior  catheterism,  as  was  done  by 
Hunter,  Verguin  and  Brainard.  For  this  purpose  the  punc- 
ture into  the  bladder  is  made  in  the  linea  alba  somewhat 
above  the  symphysis.  A  thin  elastic  catheter,  armed  with 
a  curved  mandrin,  is  pushed  through  the  canula  into  the 
vesical  orifice  of  the  urethra  through  the  membranous 
part  to  the  wound,  which  was  made  by  splitting  the  crushed 

*  Ranke,    Beitrag   zum   Catheterismus  posterior.     Deutsche   medicin. 
Wochenschrift.     1876.     Nos.  6  and  29. 


154  SURGICAL  EMERGENCIES. 

or  strictured  part.  Thereupon  a  thread  is  fastened  to  the 
point  of  the  catheter,  which  projects  into  the  wound,  while 
the  beak  of  a  Nelaton's  catheter  is  attached  to  the  other 
end  of  the  thread  and  then  the  latter  is  drawn  into  the 
bladder  through  the  wound.  Then  a  second  catheter,  in- 
serted through  the  meatus,  may  be  attached  to  the  free  end 
of  Nelaton's  catheter,  which  is  drawn  in  through  the  wound, 
thence  through  the  urethra  until  it  projects  from  the  meatus. 
When  the  outflow  of  urine  through  the  wound  has  emptied 
the  bladder  the  operator  may  be  compelled  to  substitute 
the  simple  puncture  by  hypogastric  cystotomy  (sectio  alta) 
so  as  to  enable  him  to  make  posterior  catheterism.  After 
introducing  the  catheter  through  the  abdominal  wound, 
and  thence  through  the  vesical  opening  of  the  urethra,  the 
canula  which  rests  in  the  bladder  may  be  removed  entirely, 
which  appears  less  dangerous  when  we  remember  that  it  is 
permissible  to  allow  a  canula  to  remain  in  situ  from  six  to 
ten  days  for  the  purpose  of  forming  a  vesico-abdominal 
fistula.  Likewise  posterior  catheterism  is  recommended  for 
gun-shot  wounds  of  the  urethra  in  military  surgery. 

Foreign  bodies  may  so.  block  the  urethra  as  to  produce  com- 
plete retention  of  urine.  Such  foreign  bodies  usually  des- 
cend from  the  bladder  into  the  urethra  and  become  wedged  in 
there  (renal  calculi,  small  vesical  calculi,  fragments  of  stone 
after  lithotripsy)  or  they  may  be  introduced  from  without  by 
masturbation  (stones,  pins,  needles,  sticks,  lead-pencils, 
straws,  corn,  pits  of  fruit),  or  they  are  the  result  of  the 
breaking  off  of  instruments  which  have  been  introduced  in 
surgical  operations  (catheters,  bougies,  etc.).  The  removal 
of  foreign  bodies  is  indicated  first  on  account  of  the  pri- 
mary retention  of  urine  ;  then  because  the  presence  of  the 
foreign  bodies  may  produce  inflammation  and  swelling  of 
the  urethral  walls  and  produce  secondary  retention,  and 
furthermore,  because  the  body  that  has  been  wedged  in,  if 
left  to  itself,  will  be  removed  only  by  suppuration,  ulcera- 
tion and  perforation  of  the  surrounding  tissues.  Foreign 
bodies  which  rest  directly  behind  the  cutaneous  urethral  slit, 
as  in  the  fossa  navicularis,  may  be  removed  by  forceps  or 
scoop-like  levers  in  case  simple  pressure  does  not  suffice  to 
extrude  them.  In  urgent  cases  the  urethra  may  be  split 
from  above  downwards  at  its  cutaneous  part,  and  thus 
somewhat  enlarged.  Rounded  bodies  that  have  slipped  in 
more  deeply  may  be  removed  by  Leroy  d'Etoilles'  curette 
articulee,    the   closed    lever-end  of  which  is    inserted  and 


SURGICAL  EMERGENCIES.  155 

passed  beyond  the  foreign  body,  then  its  flap  is  brought  to 
a  right  angle  to  the  long  axis  of  the  instrument  by  a  screw 
apparatus  in  its  handle.  The  foreign  body  may  be  drawn 
forth  by  the  scoop  thus  formed.  Long  bodies  (sticks,  pieces 
of  catheter,  etc.)  will  require  fine  forceps,  like  those  of  Colin, 
for  their  removal,  or  an  instrument  may  be  used  which  is 
modeled  after  the  grasping  bilabial  and  trilabial  instru- 
ments which  were  formerly  employed  as  lithotrites.  In 
these  a  bent  grasping  arm  passes  through  a  tube  and  may 
be  pushed  out  of  it  (Hale's  and  Hunter's  forceps).  When 
the  foreign  body  is  about  to  be  grasped,  the  left  hand  must 
crowd  it  from  the  root  of  the  penis  towards  the  instrument. 
A  pin  which  lay  in  the  urethra  with  its  head  towards  the 
bladder  and  its  point  forward,  was  extracted  by  Dieffen- 
bach,  who  pressed  on  the  head  of  the  pin  through  the  rectum 
and  forced  the  point  through  the  perinum  outwards,  where 
it  was  grasped  by  a  forceps  and  extracted.* 

Secondly,  cystotomy  is  indicated  in  chronic  swelling  of 
the  prostate,  whereby  new  inflammatory  increase  of  the 
gland  results  in  an  absolute  impermeability  of  the  urethra. 
As  a  rapid  increase  of  the  contents  of  the  bladder  produces 
an  engorgement  of  the  plexus  venosus  pudendus,  therefore 
evacuation  of  the  bladder  by  cystotomy  often  produces  a 
rapid  and  frequently  long-continued  decrease  of  the  swel- 
ling of  the  gland  by  reduction  of  its  sanguineous  contents. 

Similarly,  cystotomy  acts  in  tumors  of  the  pelvis,  which 
compress  the  prostatic  part  of  the  urethra.  In  these  the 
evacuation  of  the  bladder  relieves  the  engorgement  and  the 
venous  repletion  of  the  tumor  is  reduced  so  that  the  flow 
of  the  urine  through  the  urethra  is  re-established.  As  to 
the  various  procedures  in  cystotomy  we  can  advocate  but 
one,  namely,  hypogastric  puncture.  We  mention  the  other 
methods  merely  not  to  leave  them  unnoticed: 

First,  perineal  puncture,  in  which,  with  or  without  pre- 
viously slitting  the  skin,  the  trocar  is  plunged  into  the 
bladder  in  the  same  course  as  is  traversed  in  lateral  litho- 
tomy. This  procedure  is  not  recommendable  because  of 
the  considerable  injuries  which  it  entails. 

Cystotomy  through  the  rectum  is  equally  reprehensible, 
on  the  one  hand  because  permanent  insertion  of  a  canula 
appears  impossible,  and,  secondly,  because  the  operation  is 
rendered    extremely    difficult  when    there    is   considerable 

*  Dieffenbach,  Operat.  Chirurgie.     Bd.  I.  p.  44. 


l$6  SURGICAL  EMERGENCIES. 

swelling  of  the  prostate,  and,  furthermore,  it  does  not  ex- 
clude the  possibility  of  injuries  to  the  peritoneum.  In 
women  it  has  been  proposed  to  puncture  the  bladder 
through  the  anterior  vaginal  wall,  but  then  in  all  probability 
a  vesico-vaginal  fistula  will  result,  requiring  another  opera- 
tion for  its  closure.  Finally,  we  will  mention  Voillemier's 
subpubic  puncture.  In  it  the  penis  is  drawn  vigorously 
downwards  and  the  trocar  is  inserted  sideways  into  the 
suprapenal  ligament  and  sharply  turned  around  the  sym- 
physis, to  be  conducted  into  the  bladder. 

The  safest  and  most  convenient  means  is  suprapubic  cysto- 
tomy. In  it  injuries  to  the  peritoneum  rarely  occur,  because 
whether  a  swollen  prostate  or  pelvic  tumor  compress  the 
neck  of  the  bladder,  the  latter  organ  will  be  lifted  and 
crowded  against  the  suprapubic  region,  consequently  the 
perineum  will  be  lifted  out  of  the  way.  The  relations  are 
shown  most  clearly  in  the  experiments  of  Braune  and 
Garson  *  on  dislocations  of  the  bladder  and  of  the  perineum 
in  dilatation  of  the  rectum.  We  can  always  produce  the 
crowding  upward  of  the  bladder  and  displacement  of  the 
peritoneum  by  inserting  a  colpeurynter-like  apparatus  high 
up  into  the  rectum  and  distending  it  with  air  or  water. 

The  operation  is  best  executed  by  first  making  a  small 
incision  over  the  symphysis  in  the  linea  alba  through  the 
skin,  which  has  been  well  shaved,  and  then  between  the 
muscles.  Thereupon  a  semilunar-curved  trocar  (Mery, 
Frere-Cosme)  is  thrust  through  the  wound  at  a  distance  of 
about  one  to  two  cm.  above  the  symphysis. 

After  removal  of  the  stylet  the  canula  is  allowed  to  re- 
main from  six  to  ten  days,  which  results  in  the  rapid  forma- 
tion of  a  vesical  fistula.  The  removal  of  the  canula  from 
the  fistula  is  permissible  only  after  the  urethral  stream  is 
re-established.  The  vesical  fistula  heals  very  rapidly  after 
r&moval  of  the  canula  in  a  similar  manner  as  we  have  ob- 
served in  the  wounds  of  tracheotomy.  Bell  devised  a 
catheter-shaped  rounded  little  tube  to  be  pushed  through 
the  canula  and  to  cover  its  intracystic  end  to  protect  the 
wall  of  the  bladder  against  such  irritation  as  the  margins 
of  the  canula  might  produce.  To  facilitate  the  removal  of 
the  canula  from  the  bladder  a  bent  staff  (Zang's   "  Docke") 

*  Garson,  Ueber  die  Dislocation  der  Harnblase  und  des  Peritoneum 
bei  Ausdehnung  des   Rectum.     Archiv  f.    Anat.   und  Physiol.      1878. 
'VAnat.  Abth 


SURGICAL  EMERGENCIES.  157 

must  be  inserted  through  the  canulainto  the  bladder.  The 
canula  can  be  removed  and  again  inserted  over  the  guide 
thus  established.  The  canula  may  be  fixed  into  the  bladder 
by  attaching  threads  to  its  shield  and  fastening  them  to  the 
abdomen  with  adhesive  plaster  or  by  tying  the  ligatures  to 
bundles  of  the  pubic  hairs  just  as  the  fixation  of  a  perman- 
ent catheter  can  be  made  (Thompson). 

The  application  of  antiseptic  bandages  must  be  omitted, 
as  is  self-evident;  but  it  is  recommendable  to  insert  a  piece 
of  lint  which  has  been  anointed  with  carbolized  vaseline  (2 
to  3  per  cent)  several  times  a  day  between  the  plate  of  the 
canula  and  the  skin.  The  mouth  of  the  canula  may  be 
stoppered  with  a  plug  of  carbolized  wax  so  that  the  evacu- 
ation of  urine  may  take  place  only  at  certain  intervals  or 
the  urine  may  be  allowed  to  flow  off  through  a  long  rubber 
tube  which  conducts  to  a  vessel  filled  with  a  carbolic  acid 
solution.  It  goes  without  saying  that  the  patient  must 
remain  in  bed  until  the  canula  is  removed. 

Injuries  to  the  bladder  are  made  by  blunt  bodies  upon 
which  patients  spit  themselves  either  through  the  rectum 
or  perineum,  as  also  in  multiple  rupture  of  the  pelvic  bones, 
and  most  frequently  by  gun-shot.  Injuries  by  lances  or 
arrows  are  more  rare.  In  but  about  one  quarter  of  the 
cases,  the  injury  is  intra-peritoneal  while  extra-peritoneal 
injuries  are  far  more  frequent.  Traumatisms  of  the  blad- 
der are  often  united  with  injuries  to  the  pelvis  and  to  the 
rectum,  as  has  been  noted.  Bartels  *  found  74  coincident 
lesions  of  the  rectum  and  196  cases  of  coincident  injuries 
to  the  pelvic  bones  in  504  cases.  Gun-shot  wounds  of  the 
bladder  are  usually  perforating,  as  the  ball  frequently 
penetrates  the  bladder  in  two  places.  It  is  but  rare  that 
the  ball  remains  in  the  anterior  wall  of  the  bladder,  as  in 
extra-peritoneal  injuries,  and  yet  more  rarely  has  it  been 
found  to  penetrate  the  anterior  wall  and  remain  imbedded 
in  the  posterior  wall,  f  There  it  may  remain  for  many 
years  unnoticed  until  symptoms  of  stone  present  and  call 
attention  to  the  foreign  body.  The  same  applies  to  sticks, 
arrow-heads,  fragments  broken  from  the  pelvic  bones,  etc., 
which  have  penetrated  into  the  bladder. 


*  Bartels,  Die  Traumen  der  Harnblase.  Archiv  f.  klin.  Chirurgie. 
Bd.  XXII.  Heft  3  and  Heft  4. 

f  Wilms  und  Bartels,  VIII.  Congr.  d.  deutschen  Ges.  f.  Chir.  Ver- 
handl.,  p.  74-76  of  kleineren  Mittheil, 


158  SURGICAL  EMERGENCIES. 

Intra-peritoneal  injuries  to  the  bladder  have  terminated 
fatally  in  most  instances.  In  these,  the  evacuation  of  urine 
into  the  abdomen  does  not  provide  the  fatal  essential. 
Undecomposed  urine  in  limited  quantities  has  been  reab- 
sorbed bv  the  peritoneal  cavity  without  injury,*  but  the 
complicated  character  of  injuries  to  the  bladder  usually 
brings  with  it  a  decomposition  of  the  urine  and  thus  gives 
cause  for  the  appearance  of  fatal,  diffuse,  septic  peritonitis 
if  the  walls  of  the  bladder  have  been  directly  injured  or  if 
its  peritoneal  covering  be  but  lightly  furrowed.  As  soon 
as  the  crushed  serous  surface  becomes  necrosed,  the  carriers 
of  infection  enter  the  abdominal  cavity  unimpeded,  though 
later  than  in  the  case  before  mentioned.  In  the  case  of 
intra-peritoneal  injuries  to  the  bladder  tabulated  by 
Bartels  (/.  c,  131  cases  in  504)  all  terminated  fatally  with 
exception  of  a  single  one,  in  whom  a  laparotomy  was  made 
and  the  abdominal  cavity  washed  out.  This  indicates  to  us 
that  as  soon  as  a  shot  into  the  bladder  is  diagnosed  (bloody 
urine,  flow  of  urine  out  of  the  wound)  and  manifestations 
of  peritonitis  present,  we  must  proceed  to  laparotomy,  to 
disinfection  of  the  abdominal  cavity,  and,  if  possible,  to 
sewing  up  the  wound  in  the  bladder  with  introduction  of  a 
permanent  catheter  through  the  urethra.  Maximow's  f  ex- 
periments, as  well  as  the  frequently  unfortunate  cases, 
show  us  that  when  a  suture  of  the  bladder  is  made  and  the 
stitches  penetrate  the  entire  thickness  of  the  vesical  wall  it 
is  advisable  to  avoid  encompassing  the  mucous  membrane  in 
them.     The  stitches  must  be  placed  very  closely  together. 

If,  when  no  opening  of  the  abdominal  cavity  has  occurred 
our  attention  must  be  called,  in  injuries  to  the  bladder,  to 
impeded  stagnation  and  decomposition  of  the  urine  in  the 
bladder  and  in  the  wounds  which  communicate  with    it, 

*  Undecomposed  bile  as  well,  even  in  large  quantities,  does  not  exert  a 
disturbance  within  the  peritoneal  cavity.  Compare  Verhandl.  der 
deutschen  Gesellschaft  f.  Chirurgie,  VIII.  Congress,  4.  Sitzung,  April 
19th,  1879,  p.  120. — Bostroem  ligated  the  Ductus  choledochus  of  a  dog, 
with  antiseptic  precautions.  After  complete  healing,  the  right  hypochon- 
driac region  was  opened  and  a  part  of  the  wall  of  the  gall  bladder  was 
excised,  whereupon  the  abdominal  cavity  was  entirely  filled  by  the  bile 
which  had  been  engorged  in  the  gall  bladder.  The  abdomen  was  then 
sewed  up.  The  animal  survived  without  reaction.  After  eight  days  he 
was  killed  and  neither  bile  nor  coloring  matter  of  the  bile,  was  found  in 
the  bladder. 

\  Maximow,  Versuche  liber  die  Anwendung  des  Catgut  zur  Blasennaht 
bei  der  Epicystotomie.     Inaug.-Diss.     St.  Petersburg,  1876. 


SURGICAL  EMERGENCIES.  1 59 

Maas*  recommends  the  administration  of  large  doses  of 
salicylic  acid  (10  to  12  grams  per  day).  Stagnation  of  urine 
is  not  entirely  prevented  by  the  introduction  of  a  permanent 
catheter.  Narrow  wounds  must  be  split  and  free  perineal 
incision  must  be  made  to  offer  a  means  of  unimpeded  out- 
flow to  the  urine.  In  gun-shot  wounds  of  the  bladder, 
which  perforate  the  rectum,  and  where  the  urine  might 
accumulate  in  the  rectum,  Simon  recommends  cutting  the 
sphincter  ani.  Simon's  case  (1870)  thus  recovered  with, 
relative  rapidity  (Maas,  /.  c). 

Accumulations  of  fluid  within  the  uterus  occur  in  congenital 
atresia  of  the  os  or  when  the  latter  becomes  closed  as  a 
consequence  of  inflammatory  processes  (as  after  careless 
cauterizations)  and  where  stenoses  of  varying  degrees  may 
present  at  the  inner  or  the  outer  os  uteri.  The  latter  is 
more  frequent.  When  the  question  is  not  alone  one  of 
narrowing  of  the  cervix  uteri,  but  also  one  of  a  firm  exten- 
sive obliteration,  the  menstrual  blood  will  accumulate  in 
the  cavity  of  the  uterus,  become  inspissated,  and  with  each 
new  menstrual  period  will  extend  the  womb  and  the  tubes 
more  and  more  to  such  a  degree  as  to  threaten  bursting 
and  evacuation  of  the  contents  into  the  abdominal  cavity. 
Hsematometra,  which  have  been  caused  in  this  manner,  pro- 
duce inexpressible  intense  and  periodically  increasing  pains 
like  those  of  labor,  and  further  difficulties.  Peritoneal 
inflammations  in  the  surroundings  of  the  womb  frequently 
result.  This  is  particularly  important.  The  treatment  of 
haematometra  consists  of  puncture  of  the  uterus  through 
the  vagina,  with  a  curved  trocar,  preferably  through  the 
obliterated  mouth  of  the  womb,  if  it  can  be  reached.  This 
is  particularly  to  be  considered  in  so-called  unilateral  hse- 
matometra, that  is,  in  retention  of  the  menstrual  blood  in 
double  womb.  The  closure  of  a  horn  of  the  uterus  can 
result  first  from  atresia  hymenalis  of  its  vagina,  secondly 
by  atresia  of  the  horn  of  the  uterus  itself,  and  thirdly  in 
entire  or  partial  absence  of  a  vagina,  so  that  it  terminates 
immediately,  or  a  short  distance  above,  the  introitus  vaginas. 

The  puncture  must  be  made  slowly,  preferably  in  several 
operations,  so  that  the  sudden  evacuation  of  the  retained 
menstrual  blood,  with  consequent  collapse  of  the  cavity  of 
the  uterus,  may   not  produce  tearings  of  the  body  of  the 

*  Maas,  in  Konig's  Handb.  d.  Chir.     Bd.  II.  p.  360. 


l6o  SURGICAL  EMERGENCIES. 

womb,  and  especially  of  the  tubes,  on  account  of  the  above- 
mentioned  peritoneal  adhesions,  which  would  result  in 
immediate  perforations  into  the  abdominal  cavity.  Fatal 
peritonitis  frOm  perforation  by  bursting  of  a  tube  has  fre- 
quently been  the  consequence  of  too  sudden  puncture  of 
haematometra. 

Secondly,  the  evacuation  of  the  retained  menstrual  blood 
must  be  made  with  the  strictest  antiseptic  precautions  and 
a  free  outflow  of  the  uterine  contents  must  be  provided  by 
the  insertion  of  permanent  canulae  or  excision  of  pieces  of 
the  haematometra  which  present  in  the  vagina. 

If  distortions  or  marked  contractions  of  the  mouth  of  the 
womb  result  after  the  menopause  in  older  women,  then 
hydrometra  result  by  engorgement  of  the  uterine  secretions 
which  may  produce  dangers  and  difficulties  equal  to  those 
of  haematometra,  and  will  require  analogous  treatment. 
The  details  which  refer  particularly  to  these  cases,  as  well 
as  the  differential  diagnosis  of  hydrometra  from  hydrone- 
phrosis, pregnancy,  and  above  all  from  ovarian  tumors, 
must  be  sought  for  in  special  gynaecological  works.  Com- 
pare also  the  writings  of  Kussmaul,*  Fiirst,  f  Heppner,  J 
Rose,§  Schroeder,||  which  discuss  these  matters. 

*  Kussmaul,  Von  dem  Mangel,  der  Verkiimmerung  and  Verdoppelung 
der  Gebarmutter,  etc.     Wiirzburg,  1859. 

f  Fiirst,  Ueber  Bildungshemmungen  des  Uterovaginal-Canals.  Leip- 
zig, 1868. 

X  Heppner,  Ueber  einige  klinisch  wichtige  Hemmungsbildungen  der 
weiblichen  Genitalien.  St.  Petersburger  Med.  Zeitung.  N.  F.,  Bd.  I, 
Heft  3. 

§  Rose,  Ueber  die  Operation  der  Hamatometra.  Monatsschrift  fur 
Geburtskunde,  XXIX.  1867. 

I  Schroeder,  Kritische  Untersuchungen  iiber  Diagnose  der  Haema- 
tocele  retro-uterina.     Bonn,  1866. 


SURGICAL  EMERGENCIES.  l6l 


LECTURE  "XI.— (Continued.) 


III.  Contractions  of  the  Intracranial  Space  Perilous 
to  Life. — Normal  pressure  within  the  cranial  cavity. — In- 
crease of  intracranial  pressure  and  transferability  of  the  cerebro- 
spinal liquor. — Its  relations  to  the  lymphatic  circulation. — 
Cerebral  hypercemia  and  its  consequences. 

Cerebral  Compression:  Its  causes. — Intracranial  He- 
morrhages.— Injuries  to  the  venous  sinuses  and  their  treat- 
ment. —  Hemorrhages  from  the  middle  meningeal  artery. — 
Symptoms. — ligation  of  the  middle  meningeal  artery. — He- 
morrhages from  the  cerebral  division  of  the  carotid  artery. — 
Hemorrhages  between  the  dura  mater  and  pia  mater. — Re- 
duction of  space  by  fractures  of  the  skull  and  foreign 
bodies. — Complicated  injuries  to  the  skull,  prognosis,  results. 
— Symptoms  of  cerebral  contusion. — Antiseptics  in  injuries  to 
the  head. — Attainable  results. —  Treatment  of  infected  injuries 
to  the  skull. — Action  of  antiseptic  douche,  ice,  venesection,  pur- 
gatives, inunctions  of  ung.  ciner. — Operative  interference  in 
inflammatory  stage  of  wounds.  Cerebral  Abcess. — Diffi- 
culties of  diagnosing  locality. —  Treatment  of  open  and  covered 
cerebral  abscesses. — Cerebral  motions. — Causes. — Absence  of 
cerebral  motions. — Treatment  of  prolapsus  cerebri. 

Concussion  of  the  Brain,  Commotio  Cerebri. — Symp- 
toms.— Pure  and  complicated  descriptions. —  Theories. — Light 
and  severe  cases. — Course  and  termination. —  Treatment  of  con- 
cussion of  the  brain  and  s equate. 

Trepanning. — Indications. — Instruments. — Mode  of  pro- 
cedure.— Processes  which  occur  in  wounds  from  trepanning. 

The  disturbances  which  ^are  produced  by  contractions  of 
space  within  the  cavity  of  the  skull  interest  us  particularly, 
partly  because  of  the  diagnostic  difficulties  which  they  offer 
and  partly  because  of  their  eminently  dangerous  signifi- 
cance. Therefore  we  have  deferred  their  detailed  consi- 
deration until  now.  The  establishment  of  precise  and  clear 
points  of  view  for  the  treatment  of  the  disturbances  is  of 


l62  SURGICAL  EMERGENCIES. 

the  greatest  importance  here.  And  perhaps  in  no  other 
domain  have  experiments  upon  animals  contributed  so  much 
to  the  elucidation  of  the  S)rmptomatology  and  for  the  ac- 
quisition of  firm  rules  for  the  institution  of  life-saving 
means. 

Finally,  there  is  no  better  measure  for  the  value  of  the 
antiseptic  treatment  of  wounds  than  that  which  results  from 
examining  the  successes  which  were  attained  in  even  the 
most  difficult  injuries  to  the  skull  and  the  brain. 

Even  such  an  exemplary  work  as  the  excellent  treatise  of 
Bergmann*  could  do  but  partial  justice  to  the  new  and  unex- 
pected therapeutic  prospects,  as  it  was  published  shortly 
before  the  antiseptic  period. 

To  thoroughly  comprehend  the  occurrences  in  contractions 
of  the  cavity  of  the  skull,  we  must  impress  upon  our  minds 
that  the  space  is  bounded  in  childhood  by  compressible  and 
extremely  elastic  bony  walls,  which,  however,  become  quite 
firm  and  less  elastic  with  increasing  years.  Within  that 
space  we  find  partly  solid  masses,  the  brain,  partly  liquids, 
like  the  blood,  lymph  and  cerebro-spinal  fluid.  The  solid 
as  well  as  fluid  parts  must  be  considered  as  incompressible 
when  subjected  to  the  ordinary  state  of  pressure  within  the 
skull.  When  limitation  of  the  cerebral  space  occurs  by  the 
introduction  of  a  foreign  body  (projectiles,  knife-blades,  etc.) 
or  by  pathological  products  (haemorrhages,  pus,  etc.)  the 
limitation  can  occur  only  by  crowding  out  the  fluid  parts. 
The  solid  brain,  on  the  contrary,  can  suffer  reduction  only 
by  partial  destruction  and  removal  from  the  cranial  cavity, 
or  in  slow  compression,  by  atrophy. 

Of  the  fluids  within  the  skull  the  cerebro-spinal  liquor  is 
most  easily  displaced.  Its  removal  from  rather  large  space 
is  made  possible  because  of  the  free  communication  of  the 
sub-arachnoid  spaces  of  the  brain  with  the  arachnoid  spaces 
of  the  spinal  marrow.  The  latter,  the  spinal  dura  mater, 
is  capable  of  considerable  extension;  first,  by  the  com- 
pressibility of  the  venous  plexuses,  which  lie  around  the 
spinal  dura  mater  within  the  spinal  canal;  secondly,  by  the 
elasticity  of  the  lig.  flava,  which  are  stretched  between  each 
vertebral  arch  by  those  of  the  membrana  obturatoria  atlan- 
tis  anter.  et  post.,  as  also  by  those  of  the  sheaths  of  the 
structures  within  the  inter-vertebral  orifices. 


*  Bergmann,  Die  Lehre  von  den  Kopfverletzungen.     Pitha  und  Bill- 
roth's  Sammelwerk,  III.,  Bd.,  I  Abth.     1873. 


SURGICAL   EMERGENCIES.  163 

Furthermore,  it  is  important  to  consider  that  all  of  the 
blood-vessels  of  the  brain — arteries,  as  well  as  veins — are  in- 
volved by  perivascular  lymph-canals  (His*)  the  contents  of 
which  are  emptied  into  the  epicerebral  lacunae.  The  latter 
are  in  communication  with  the  arachnoid  sac  between  pia 
and  dura  mater  and  also  with  the  sub-arachnoid  spaces  by 
means  of  the  lymph-vessels  of  the  pia  mater  (Golgi,  Key, 
and  Retziusf).  The  significance  of  these  spaces  as  lymph- 
spaces  was  shown  by  SchwalbeJ  ;  their  lymph  to  a  certain 
extent  is  poured  into  the  branches  which  unite  to  form  the 
internal  jugular  plexus,  and  thus  they  reach  the  lymph-ves- 
sels of  the  neck  (Arnold). 

The  lymphatic  circulation  is  capable  of  serving  as  a  reg- 
ulator only  in  gradual  changes  in  the  volume  of  the  cranial 
contents.  The  changes  in  the  quantity  of  blood  in  the  brain 
which  are  brought  about  by  the  systole  and  expiration,  and 
more  so,  all  greater  and  sudden  changes  of  volume  w7ithin 
cranial  cavity,  call  forth  questions  as  to  the  modifications 
which  result  from  variations  in  the  tension  of  the  cerebro- 
spinal liquor. 

Such  changes  in  tension  within  the  cranial  space  are 
caused  primarily  by  a  repletion  of  blood  in  the  brain, 
be  it  that  a  fluctionary  arterial  hyperaemia,  or  that  venous 
engorgement  prevails.  In  both  instances  the  tension  of  the 
cerebro-spinal  fluid  finally  rises  so  high  that  a  compression 
of  individual  capillary  districts  in  the  cerebral  circulation 
is  brought  about.  The  impediments  to  the  movement  of 
blood  thus  caused,  bring  about  the  retardation  of  the  arterial 
current  in  the  brain.  This  retardation  causes  the  nutrition  of 
the  brain-centres  to  suffer  in  a  similar  manner  as  they  do  when 
there  is  a  reduction  of  the  mass  of  blood  which  flows  through  the 
brain,  thus  as  in  cerebral  ancemia  (Althann  §).  The  above 
conditions  are  particularly  observable  in  that  repletion  of 
the  cerebral  circulation  which  is  not  dependent  upon  in- 
crease of  the  heart's  action,  but  upon  a  paralysis  of  the 
vasomotor  nerves,  with  a   relaxation  of  the  vascular  walls. 

*  His,  Ueber  ein  perivasculares  Canalsystem  in  den  Central  organen 
und  dessen  Beziehungen  zum  Lymphsystem  Zeitschrift  f.  wiss  Zoologie, 
1865,  Bd.  XV.,  p.  127. 

f  Key  and  Retzius,  Injectionen  in  die  Limphraume  der  Schiidelhohle. 
Nordisk  Medic.  Arkiv.  Centralbl.  f.  die  Med.  Wissensch.  1871,  p.  514. 

%  Schwalbe,  Der  Arachnoidealbraum  ein  Lymphraum,  Centralbl.  f.  die 
Med.  Wissensch.     1869.     No.  39. 

§  Althann,  Der  Kreislauf  in  der  Schiidelriich  gratshtile. '    Derpat,  1871. 


164  SURGICAL  EMERGENCIES. 

This  is,  as  we  shall  see,  of  importance  in  ths.  conditions 
which  follow  concussion  of  the  brain. 

All  injuries  which  limit  the  space  of  the  cranium  act  like 
hypergemias  of  the  brain.  They  increase  intracranial  pres- 
sure by  elevating  the  tension  of  the  cerebro-spinal  liquor, 
and  hamper  the  circulation  by  compression  of  the  capillaries. 
The  second  disturbances  of  nutrition  manifest  themselves 
in  modifications  of  the  brain  functions,  as  we  shall  have  to 
consider  more  in  detail  when  discussing  the  complex  num- 
ber of  symptoms  of  compression  and  concussion  of  the 
brain.  Compression  of  the  brain  is  brought  about  when  the 
space  within  the  skull  is  limited.  In  chronic  limitations  of 
the  space,  as  we  see  it  in  osteo-sclerosis  cranii,  when  the 
cranial  cavity  contracts  in  all  its  parts,  or  in  exostoses  or 
tumors,  which  grow  from  the  cranial  capsule  towards  the 
brain,  and  exert  local  contraction,  no  cerebral  pressure  oc- 
curs. The  quantity  of  cerebro-spinal  fluid  accommodates 
itself  to  these  encroachments,  or  the  otherwise  incompres- 
sible brain  is  reduced  by  atrophy.  The  symptoms  of  brain- 
pressure,  however,  are  observed  immediately  in  sudden 
compression  of  the  skull  on  all  sides,  as  Schwartz*  proved 
experimentally  with  very  young  animals.  The  same  symp- 
toms are  seen,  furthermore,  when  a  traumatism  crowds  the 
bony  skull  wall  in  toto  inwards  at  any  place. 

The  manifestations  of  compression  of  the  brain  will  thus 
be  most  frequently  observed  as  the  results  of  forces  which 
directly  strike  the  skull,  consequently  in  injuries  to  the  head. 
Among  the  consequences  we  note  extravasations  of  blood 
within  the  cranial  cavity,  or  fractures  of  the  skull,  with 
depression  or  penetration  of  foreign  bodies,  or  finally, 
accumulations  of  inflammatory  exudations,  which  are  the 
essential  elements  to  a  pressure  on  the  brain. 

In  extravasations  of  blood,  penetration  of  bone-splinters 
and  foreign  bodies,  the  manifestations  of  cerebral  compres- 
sion will  follow  the  injury  immediately  or  occur  very  soon 
thereafter  ;  consequently  we  designate  them  as  primary 
symptoms.  In  the  accumulation  of  inflammatory  products 
within  the  cerebral  cavity  the  symptoms  of  cerebral  pressure 
occur  only  a  length  of  time  after  the  injury  and  conse- 
quently bear  the  name  of  secondary  symptoms. 

Extravasation  of  blood  is  the  most  frequent  cause  of  primary 
cerebral   compression."     It  may   occur  from  any  of  the  ves- 

*  Schwarz,  Archiv.  f.  Gynokologie.     1870.     Bd.  I.,  p.  364. 


SURGICAL  EMERGENCIES.  165 

sels  of  the  interior  of  the  skull.  The  manifestations  of 
cerebral  pressure,  when  haemorrhage  occurs,  appear  some- 
what later  than  in  depressed  fracture,  because  the  effused 
mass  of  blood  must  acquire  certain  dimensions  before  a 
dangerous  increase  of  the  intracranial  tension  can  take  place. 
Therefore  small  quantities  of  blood  can  be  poured  out 
without  any  further  symptoms  being  developed,  but  they 
may  assert  themselves  when  arterial  hyperemia  or  inflam- 
matory processes  occur  with  the  haemorrhage. 

Haemorrhages  of  the  skull  occur  either  outwards  or  in- 
wards, or  synchronously  in  both  directions.  Haemorrhages 
outwards  are  usually  from  the  sinuses  of  the  dura  mater, 
from  the  meningeal  artery,  and  (rarely)  from  the  internal 
carotid.  When  these  vessels  are  injured  without  open  frac- 
ture of  the  skull  the  blood  is  usually  poured  between  the 
dura  mater  and  the  cranial  bones. 

Injuries  to  the  walls  of  the  sinuses  occur  usually  by  instru- 
ments which  have  perforated  the  cranial  cavity,  or  by  bits 
which  have  been  splintered  off  from  the  bony  cranial  walls, 
be  it  that  the  fracture  of  the  skull  is  complicated  with  in- 
jury to  the  soft  parts  of  the  skull  or  not,  and  finally  in 
stretching  or  extension  of  the  sinus  when  the  capsule  of 
the  skull  is  pressed  together.  Such  ruptures  of  the  walls 
of  the  sinus  occur  in  births  when  the  child's  head  passes 
through  a  narrow  pelvis.  Again,  they  occur  in  fractures 
of  the  bones,  especially  those  of  the  base  of  the  skull.  True 
ruptures  more  frequently  affect  the  transverse  sinus 
than  they  do  the  longitudinal  one.  The  latter,  however, 
is  more  frequently  exposed  to  injury  by  foreign  bodies, 
which  strike  the  cranial  arch.  The  cavernous  sinus  is  also 
injured  when  perforating  instruments  penetrate  the  inner 
orbital  wall.-  Injury  to  the  sinus  confluens  is  of  rare  oc- 
currence. 

When  wounds  in  the  sinus  communicate  with  a  compli- 
cated fracture  of  the  skull  and  the  blood  flows  only  out- 
wards, the  haemorrhage  may  be  arrested  in  most  cases  by 
direct  compression  of  the  wound.  However,  when  the  blood 
accumulates  between  the  cerebral  bones  and  the  dura  mater 
dissecting  off  the  latter  in  ever-increasing  extent,  symptoms 
of  cerebral  compression  finally  manifest  themselves.  But 
they  result  more  slowly  than  when  the  extravasation  of 
blood  takes  place  from  the  meningeal  artery.  Yet  cases 
occur,  where,  owing  to  the  peculiar  position  of  the  wound 
in  the  sinus,  the  blood  cannot  accumulate  between  the  dura 


l66  SURGICAL  EMERGENCIES. 

mater  and  the  bone  ;  then,  of  course,  symptoms  of  cerebial 
compression  are  absent. 

Schellmann's*  experiments  show  that  wounds  inthe  sinus 
can  heal  without  their  obliteration.  Nor  does  the  closure 
of  a  large  sinus  by  a  thrombus  bring  about  any  disturbance 
in  the  cranial  circulation,  provided  that  there  are  no  con- 
tinued thrombi  nor  disintegration  of  disinfected  thrombi 
with  consequent  metastatic  pyaemia. 

Injuries  to  sinuses  of  the  dura  mater,  though  they  pre- 
sent no  dangerous  or  not  easily  controllable  haemorrhages, 
may  still  result  fatally  because  of  entrance  of  air  (Volkmann, 
Genzmer  f ).  Hmnorr hag es  from  the  meningeal  artery  usually 
are  brought  about  by  fractures.  Either  a  splintered  piece 
of  bone  penetrates  the  vessel,  or  the  vessel  is  torn  when  its 
long  axis  is  crossed  by  the  line  of  fracture  in  the  bone. 
But  the  meningeal  artery  may  also  be  torn,  in  simple  press- 
ing-in  of  the  bone  without  interruption  of  its  continuity, 
because  the  artery  lies  bedded  in  a  deep  furrow  in  the  bone 
and  is  closely  united  to  it  by  its  perforating  branches, 
which  enter  the  bone.  This  will  explain  how  tearing  of 
the  meningeal  artery  may  occur  without  the  application  of 
force  directly  over  the  artery.  A  blow  upon  the  left 
temporal  region  may  produce  a  tearing  of  the  right  menin- 
geal artery. 

The  most  dangerous,  often  fatal,  haemorrhages  are  from 
the  middle  meningeal  artery,  which  often  yield  considera- 
ble accumulations  of  blood  within  the  cranium.  If  a 
complicated  injury  allows  the  blood  to  escape  outwards, 
the  haemorrhage  might  be  confounded  with  haemorrhage 
from  the  deep  temporal  artery.  The  real  condition  in  this 
instance  is  quickly  discernible  by  dilatation  of  the  wound 
and  finding  and  ligating  the  injured  vessel. 

Hcemorrhage  from  the  middle  meningeal  artery  into  the  skull 
produces  symptoms  of  cerebral  pressure,  with  continued 
increase  of  the  symptoms  of  compression  quickly  after  the 
injury.  Only  in  exceptional  cases  was  the  appearance  of 
symptoms  of  compression  observed  after  the  lapse  of  some 


*  Schellmann,  Ueber  die  Verletzum,  gen  der  Hirnsinus.  Inaug.-Diss. 
Giessen. 

f  Genzmer,  Exstirpation  eines  faustgrossem  Fungus  dura  matris,  todt- 
lich  verlanfen  durch  Lufteintritt  in  den  geoffneteu  sinus  longitudinalis. 
Verhandl.  d.  deutschen  Gesselsch.  f.  Chirurgie,  IV.  Congr.  1877.  Gros- 
sere  Vortrage,  p.  3. 


SURGICAL  EMERGENCIES.  167 

time.  But  rarely  do  these  symptoms  decrease  in  intensity. 
In  most  instances  they  become  more  and  more  severe. 

The  initial  headache  is  followed  by  vomiting,  dullness, 
somnolency,  sleep,  snoring  respiration,  and  marked  slowing 
of  the  pulse  ;  the  respiration  becomes  more  difficult  and 
labored,  rattling  in  the  throat  is  heard,  and  death  occurs  in 
deep  coma.  This  order  of  symptoms  is  often  modified  and 
associated  with  other  cerebral  manifestations,  as,  for  in- 
stance, paralysis  in  case  the  injury  to  the  vessels  is  accom- 
panied by  lesions  of  the  brain  which  most  frequently  is 
crushed.  In  the  latter  instances  the  cerebral  manifestations 
occur  more  quickly  after  the  injury.  Symptoms  of  pres- 
sure which  follow  perhaps  eight  days  after  the  injury  can 
not  be  referred  to  a  haemorrhage  of  the  meningeal  artery. 

Whenever  an  injury  occurs  to  the  temporo-parietal  region 
with  haemorrhage  outwards  and  rapidly  increasing  symp- 
toms of  brain-pressure,  followed  by  paralysis  of  the  opposite 
side,  we  must  enlarge  the  wound,  elevate  or  remove  splin- 
ters, and  proceed  to  baring  the  injured  artery,  be  it  by  the 
use  of  a  trephine  or  by  enlarging  the  orifice  in  the  bone 
with  a  hammer  and  chisel  so  as  to  reach  the  artery  conven- 
iently, that  it  may  be  ligated  or  compressed.  The  compres- 
sors which  were  recommended  by  Von  Grafe  for  the  control 
of  haemorrhage  from  the  meningeal  artery  have  proven 
impracticable. 

Seeking  for  the  meningeal  artery  is  also  indicated  in  each 
complicated  fracture  of  the  temporo-parietal  region,  even 
when  no  haemorrhage  outwards  occurs,  whenever  marked 
symptoms  of  cerebral  compression  assert  themselves, 
shortly  after  the  injury  (Keate,  Tatum  *).  We  will  be  justi- 
fied in  baring  the  meningeal  artery  according  to  Hueter's 
procedure,!  even  though  the  soft  parts  over  the  fractured 
skull  be  intact,  when  increased  swelling  of  the  temporal 
region  and  marked  symptoms  of  compression  occur;  more 
so  as  the  unfavorable  terminations  which  as  yet  have  taken 
place  in  this  interference  must  be  attributed  in  great  part 
to  a  neglect  of  antiseptic  precautions.  As  proof  thereof  a 
case  of  recovery  after  ligation  of  said  artery  was  recently 
reported  by  Hueter.J 

*  Prescott  Hewett,  Holmes'  System  of  Surg.,  Vol.  II.,  p.  108. 

f  Hueter,  Virchow.     Hirsch's  Jahresberlcht.     1870.     Bd.    II.,  p.  352. 

X  Hueter  ein  Fall  von  Heilung  einer  schweren  Schadelverletzung  mit 
Umstetchung  der  Art.  menigea  media,  Centralbl.  f.  Chi/.  1879,  No.  34, 
P.  553- 


1 68  SURGICAL  EMERGENCIES. 

The  life-saving  significance  of  the  above  procedure  in 
the  almost  invariably  fatal  intracranial  haemorrhages  make 
it  appear  desirable  that  ligatio?i  of  the  middle  meningeal  artery 
be  practiced  as  a  typical  operation.  The  procedure  is 
described  more  in  detail  by  Vogt.* 

After  splitting  the  soft  parts  by  an  incision  ascending 
about  4  cm.  upwards  from  the  middle  of  the  zygomatic 
arch,  which,  however,  may  be  substituted  by  a  crucial  in- 
cision, or  by  a  tongue-shaped  temporal  flap,  attached  to  the 
upper  margin  af  the  zygomatic  arch  by  its  base  and  which 
can  be  turned  down,  the  lateral  cranial  wall  is  exposed,  and 
the  periosteum  split  and  levered  off.  Then  the  trephine  is 
set  in  an  angle  formed  by  the  intersection  of  two  lines,  of 
which  one  is  about  3  cm.  above  the  zygomatic  arch  and 
parallel  to  it,  while  the  other  courses  perpendicularly  to  the 
first  and  terminates  about  2  cm.  behind  the  spheno-frontal 
process  of  the  zygomatic  bone.  After  removal  of  the  disk 
of  bone  the  artery  must  be  surrounded  at  both  sides  of  the 
site  of  injury.  After  removal  of  the  accumulated  blood  we 
will  be  compelled  to  incise  the  dura  mater  itself  above  the 
district  of  ligation,  so  as  to  free  whatever  blood  may  have 
been  poured  out  between  the  dura  mater  and  arachnoid. 
Thorough  washing  of  the  wound  with  three-per-cent  solu- 
tion of  carbolic  acid,  thorough  drainage,  suture  of  the 
wound  (when  the  lips  of  the  Wound  are  clean,  or  after 
intentional  split  of  the  integumentary  coverings),  as  well  as 
an  extensive  well-fitting  antiseptic  bandage  must  follow. 

Hcemorrhages  from  the  cerebral  carotid  have  not  been  ob- 
served often.  As  the  artery  lies  but  loosely  in  the  carotid 
canal  of  the  petrous  portion  with  an  expansion  of  the  sinus 
cavernosus,  therefore  it  is  not  often  torn  in  fractures  of  the 
petrous  portion.  Beck  f  describes  perforation  of  the  inter- 
nal carotid  by  a  splinter  of  bone  from  the  sphenoid.  A 
similar  occurence  might  take  place  by  balls  which  have 
penetrated  and  become  fixed  in  the  petrous  portion,  in  time 
destroying  the  arterial  wall  by  erosion  (Lpngmore  J). 
Nelaton's  §  case,  which  has  been  often  cited,  certainly  is  a 
rarity,  showing  penetration  of  a  splinter  of  bone  through  the 
cavernous  sinus  into  the   internal  carotid  after  a  blow  on 


*  Vogt,  Deutcshe  Zeitschrift,  f.   Chir.    1872.     Bd.  II.,  Heft.  2,  p.  165. 

f  Beck,  Die  Schudelberletzungen.     Freiburg,  1875.     p.  39. 

%  Holmes'  System  of  Surg.,  Vol.  II.,  p.  87. 

§  Demarquay,  Traite  des  tumeurs  de  l'orbite.     Paris,  i860. 


SURGICAL  EMERGENCIES.  169 

the  left  eye  with  a  stick.  An  arteriovenous  aneurism  re- 
sulted. The  patient  died  four  months  later  of  hemorr- 
hages from  the  nose. 

Hemorrhages  behveen  the  dura  and  pia  mater  into  the 
so-called  sac  of  the  arachnoid  occur  most  frequently  by 
tearing  veins  which  course  from  the  surface  of  the  brain 
and  from  the  pia  mater  to  the  longitudinal  sinus.  The  blood 
may  also  be  derived  directly  from  the  latter.  Coincident 
with  them  are  lesions  of  the  brain  and  haemorrhages  into 
the  tissue  of  the  pia  mater  and  into  the  sub-arachnoid 
spaces. 

The  cause  for  the  above  accumulations  of  blood  are 
mostly  severe  injuries,  or  great  displacements  of  the 
cranial  bones  during  birth.  The  symptoms  which  herein 
appear  refer  either  directly  to  crushing  of  the  brain  or  in 
case  large  veins  have  been  torn,  cerebral  pressure  may 
be  developed,  though  but  slowly. 

Fractures  of  the  bony  walls  of  the  skull,  which  involve  either 
both  plates  equally,  or,  as  is  most  frequent,  the  inner  table 
to  a  greater  extent  than  the  outer,  and  but  rarely  affect 
the  inner  table  alone,  may  produce  a  limitation  of  space  in 
the  cranial  cavity  in  various  ways.  The  outflow  of  cerebro- 
spinal fluid  alone  implies  a  greater  venous  repletion  of  the 
brain  with  retardation  of  the  circulation.  Depressed  frag- 
ments of  bone  bring  about  symptoms  of  compression,  by 
direct  mechanical  impingement,  more  so  than  do  splinters 
of  bone  or  fractured  pieces  which  perforate  the  dura  mater 
and  are  wedged  into  the  brain.  Foreign  bodies  (bullets, 
knife-blades,  etc.),  which  become  imbedded  into  the  brain, 
conduct  themselves  analogously  to  the  behavior  of  splin- 
ters. The  entity  of  the  manifestations  depends  upon  the 
amount  of  lesion  to  the  brain  and  to  that  of  the  intracranial 
vessels.  Haemorrhages  and  crushings  of  the  brain  are 
almost  invariably  found  in  traumatisms  in  which  the  brain 
capsule  is  perforated  at  any  part.  Thus  a  depression  of 
bone  with  coincident  extravasation  of  blood  can  produce 
evidences  of  compression,  the  existence  of  which  is  more 
clearly  established  when  the  manifestations  continue,  not- 
withstanding elevation  of  the  bone  fragments. 

As  injuries  to  the  skull  have  their  course  determined  by 
the  results  of  the  injuries  to  the  brain,  so,  inversely,  does 
the  course  of  brain-lesion  depend  upon  the  condition  of 
the  outer  wound,  and  upon  the  protection  against  infec- 
tion, which  the  latter  does  or  does  not  receive. 


170  SURGICAL   EMERGENCIES. 

Previous  to  the  introduction  of  antiseptic  treatment  of 
wounds  the  usual  terminations  of  complicated  cerebral 
lesions  were  inflammatory  cedema  of  the  brain  with  diffuse 
extended  capillary  haemorrhages,  or  a  continuous  septic 
meningitis,  or  acute  progressive  encephalitis,  with  puru- 
lent infiltration  of  the  brain,  or  an  abscess  of  the  brain. 
Endeavors  have  been  made  to  demonstrate,  experimentally, 
the  purely  mechanical  influence  of  bone  splinters,  or  of 
foreign  bodies  which  have  penetrated  the  brain  in  the  pro- 
duction of  the  above  processes  (Fischer's  experiments  made, 
by  driving  nails  through  the  skull  near  trepanned  orifices, 
etc.*).  Doubtless  the  care  of  the  patient  is  of  importance 
in  determining  the  course  of  injuries  to  the  head;  it  may 
be  summed  up  in  complete  psychical  and  physical  rest, 
avoidance  of  transportation  and  permanent  application  of 
cold,  abstinence  from  liquids  which  increase  the  blood 
pressure,  and  enjoining  limited  diet.  But  we  may  safely 
assume  that  all  the  above  cited  evil  terminations  are  prin- 
cipally subject  to  the  question  of  infection  of  the  wound. 
Clinical  experiences  in  this  regard  show  us  here  as  clearly 
as  in  other  surgical  interferences,  that  the  evil  results  are 
dependent  upon  the  course  of  the  wound  and  not  upon  the  trau- 
matic inte?-ferences  as  such.  It  is  true  that  cases  have 
been  described  wherein  fatal  traumatic  meningitis  devel- 
oped in  a  cranial  cavity  which  apparently  was  closed  off 
from  the  air  by  uninjured  soft  and  bony  coverings.  Such 
descriptions  must  be  accepted  with  allowance,  because 
even  insignificant  fissures,  which  are  easily  overlooked, 
especially  at  the  base  of  the  skull,  may  serve  as  points 
of  entrance  for  matters  which  incite  decomposition.  Thus 
we  know,  according  to  Weigert's  f  views  that  even  the 
intact  region  of  the  ethmoidal  cells  may  serve  as  a  port  of 
entrance  for  infecting  matters. 

In  fact,  injuries  to  the  skull  which  are  complicated  by  in- 
significant and  difficultly  discernible  fissures,  for  instance, 
at  the  base  of  the  skull,  terminate  more  viciously  than  do 
even  considerable  wounds  of  the  cranial  arch  which  permit 
easy  examination. 

Furthermore,  those  lesions  of  the  skull  and  of  the  brain 
in   which    there   are    large   intracranial   extravasations   of 

*  Fischer,  Archiv.  f.  Klin.  Chir.,  1865.     Bd.  VI.,  p.  595. 
f  Cohnheim,  Die  Tuberculose  vom  standpunkte  der  Inflections  Lehre. 
Univ.-Programm.  Leipzig,  1879,  p.  19. 


SURGICAL  EMERGENCIES.  I? I 

blood  take  on  more*  serious  form.  The  presence  of  the 
latter  very  early  produces  strongly  marked  symptoms  of 
compression.  The  disturbance  of  the  circulation  causes 
the  nutrition  of  the  brain  to  suffer  considerably,  as  we  have 
seen,  so  that  in  these  cases  every  inflammatory  irritation, 
even  each  hyperaemia,  and  still  more  of  each  inflammatory 
oedema  of  the  brain,  each  inflammation  of  the  meninges,  or 
of  the  brain-substances  can  the  sooner  produce  conditions 
which  threaten  life.  On  the  other  hand,  here,  as  every- 
where else,  septic  influences  will  act  so  much  more  rapidly 
in  proportion  to  the  amount  of  blood,  which  forms  extensive 
coagula,  subject  to  decomposition. 

It  was  formerly  attempted  to  group  scientifically  a  spe- 
cific picture  of  the  symptoms  which  it  was  alleged  were 
characteristic  of  contusion  of  the  brain.  A  large  number 
of  these  symptoms  depend  upon  sepsis,  only  that  the  organ 
upon  which  they  exert  their  influence  and  which  re-acts  so 
sensitively  to  disturbances  of  nutrition  receives  a  special 
impress  from  it.  The  functional  disturbances  which  the 
condition  of  the  brain  produces  in  the  central  nerves  of  the 
system,  are  connected  with  injuries  to  certain  regions  of 
the  brain,  after  calling  forth  those  manifestations  which  are 
dependent  upon  sepsis. 

The  experiments  of  Broca*  (centre  of  speech),  the  funda- 
mental experiments  of  Fritsch  and  Hitzigf  on  the  motor 
centres  of  the  cerebral  cortex,  etc.,  may  be  used  to  demon- 
strate that  a  diagnosis  of  cerebral  contusion  can  only  be 
safely  made  where  functional  disturbances  of  certain  divi- 
sions of  the  brain  can  be  proven. 

However,  practically,  we  have  still  more  important  tasks 
before  us,  which  are,  to  prevent  admission  of  infectious  ma- 
terials to  lesions  of  the  skull  and  of  the  brain.  This  is  at- 
tainable only  by  strictly  following  antiseptic  treat7nent  in  all  in- 
juries to  the  head.  Our  therapeutics  can  accomplish  but 
little  or  nothing  after  progressive  inflammatory  processes 
have  been  established.  In  diffuse  meningitis,  or  in  enceph- 
alitis, or  in  puriform  destruction  of  brain-substance,  in  the 
vicinity  of  a  contusion,  in  a  necrotic  focus  or  abscess  of  the 
brain,  we  are  powerless.     It  is  only  when  inflammatory  pro- 


*  Broca,  Sur  le  siege  du  language  articule.  Bull,  de  la  Soc.  Anato- 
mique  de  Paris,  1861.     Bd.  IV. 

f  Fritsch  und  Hitzig,  Ueber  die  Elektrische  Erregbarkeit  des  Gros- 
shins,  Du  Bois'  und  Reichert's  Archiv.  f.  Physiol.,   1870. 


172  SURGICAL  EMERGENCIES. 

cesses  are  localized  and  encapsulated,  as  when  cerebral  ab- 
scesses are  sharply  defined  from  their  surroundings,  that 
their  evacuation  can  act  in  a  life-saving  manner. 

It  is  to  be  regretted  that  as  yet  diagnosis  of  the  site  in 
which  a  cerebral  abscess  is  developed,  is  still  so  difficult  and 
dependent  upon  accidental  circumstances.  Many  cases 
terminate  fatally  in  which,  had  we  possessed  more  exact 
knowledge  of  the  site  of  the  abscess,  the  symptoms  of  com- 
pression of  the  brain  could  have  been  relieved,  with  pre- 
servation of  Jife. 

When  we  are  called  to  an  injury  of  the  head  we  must  al- 
ways treat  it  as  if  it  were  complicated  with  an  opening  into 
the  cranial  cavity.  We  are  caused  to  do  this,  though  we 
do  not  find  a  perforating  fracture  of  the  skull,  when  brain 
symptoms,  and  principally  brain  pressure,  obtain.  Our  pro- 
cedures must  be  more  painful  when  we  find  a  direct  frac- 
ture of  the  skull,  or  when  a  defect  in  the  bone  allows  not 
only  the  cerebro-spinal  fluid  to  escape,  but  when  brain- 
matter  presents  traumatic  encephalocele,  or  wells  forth  in  a 
comminuted  condition. 

We  first  shave  the  region  smoothly  to  a  large  extent 
around  the  injury,  and  then  thoroughly  clean  the  skin  with 
soap  and  ether,  and  assist  this  procedure  with  a  brush. 
Thereupon  we  dilate  the  wound  in  the  soft  parts  extensively 
so  that  we  remove  whatever  pieces  of  bone  may  have  pene- 
trated the  interior  of  the  skull.  We  smoothe  the  margins 
of  the  bone  with  cutting  pliers,  and  endeavor  to  give  it  such 
a  form  as  will  allow  us  facility  in  viewing  the  dura  matter 
and  the  brain,  whether  one  or  both  of  them  are  injured.  It 
is  important  to  remove  all  the  coagula  which  have  accumu- 
lated between  the  dura  matter  and  the  bone,  as  well  as 
foreign  bodies  of  dirt  (earth,  sand,  powder,  etc.),  and  to 
wash  such  bulgings  as  may  present  themselves  carefully 
with  an  antiseptic  fluid  (three-per-cent  carbolic  acid  solu- 
tion). 

The  conditions  of  the  dura  mater  require  special  atten- 
tion. Simple  tears  and  slits  must  be  sufficiently  enlarged  to 
permit  free  evacuation  of  whatever  blood,  secretions  and 
pus  may  have  accumulated  between  the  dura  mater  and 
the  arachnoid.  Brain-masses,  that  have  been  crushed 
bodily,  are  suffused  with  blood  and  converted  into  a  loose 
pasty  mass,  may  be  washed  out.  If  decomposition  has 
begun  in  the  brain  wound  we  need  not  hesitate  to  paint 
it   thoroughly  with  an  eight-per-cent  solution  of  chloride 


SURGICAL   EMERGENCIES.  173 

of  zinc,  according  to  the  very  encouraging  experiments  of 
Socin.*  Such  painting  may  be  in  place  also  after  the 
evacuation  of  cerebral  abscesses.  So  we  need  not  hesitate 
to  insert  a  disinfected  drainage-tube  into  wounds  of  the 
skull  and  even  of  the  brain,  through  which  to  conduct  the 
secretions  from  the  wound. f 

When  the  soft  parts  are  lifted  off  in  a  flap-like  form,  the 
wound  may  be  closed  by  sutures  as  far  as  the  drainage 
tube,  as  when  the  soft  parts  are  not  severely  crushed  or  do 
not  appear  mortified,  such  sub-cutaneous  recesses  as  occur 
may  be  drained.  When  they  have  been  rendered  entirely 
aseptic,  primary  adhesions  of  the  flaps  of  skin  with  the  deeper 
soft  parts  may  be  accomplished  by  antiseptic  compression. 
The  latter  must  cover  the  entire  extent  of  the  region  of  in- 
jury or  operation  and  considerably  beyond  it.  When  apply- 
ing carbolized  gauze  the  wound  must  be  well  covered  by 
compressed  layers  of  the  dressing  closely  pressed  together, 
and  the  margins  of  the  bandage  must  be  bolstered  with 
salicylated  cotton.  The  application  of  carbolized  jute  is 
well  adapted  for  dressing  the  surface  of  the  head. 

The  ideal  of  antiseptic  treatment  of  complicated  injury 
to  the  brain  is  secured  in  the  cure  of  spontaneous  haemor- 
rhages, frequently  with  extensive  comminution  of  the  brain- 
mass  after  cerebral  apoplexies.  In  brain  injury  as  well, 
efforts  must  be  made  for  the  removal  of  extravasations  of 
blood  of  the  destroyed  parts  of  the  brain,  and  such  particles 
of  bone  which  may  have  been  driven  into  it,  thus  to  pro- 
duce as  small  a  scar  as  possible.  It  affords  extreme  satis- 
faction, though  we  can  accomplish  this  with  safety  in  ex- 
ecuting antisepsis,  of  course,  only  in  quite  recen  t  cases. 
Bergmann  (/.  c.  p.  287)  designated  these  results  as  "per- 
haps forever  beyond  our  art." 

*  Socin,  Zur  Behandlung  der  Kopfverletzungen.  Correspondenzblatt 
f.  Schweizer  Aerzte,  1876.     No.  24. 

f  In  a  number  of  experiments  I  succeeded  not  only  in  healing  in  dis- 
infected plugs  of  cork  and  rubber  into  trepanned  orifices,  but  also  in  fix- 
ing rubber  plates  between  the  dura  mater  and  trepanned  orifices.  These 
were  about  the  diameter  of  a  dime,  thus  closing  them.  The  plates  be- 
came fixed  without  at  all  disturbing  the  condition  of  the  rabbit.  At  those 
sites  in  which  the  plate,  or  the  cork,  or  rubber  stopper  lay  upon  the 
brain,  a  depression  of  the  brain  substance  was  frequently  found.  Yellow- 
ish flakes  of  fibrine  were  rarely  found  between  the  plate  and  the  brain: 
The  operations  were  performed  strictly  under  Lister's  rules.  The  wound 
was  closed  in  each  instance  directly  by  deep  mattress-sutures  and  by  sup- 
erficial sutures. 


174  SURGICAL  EMERGENCIES. 

When  processes  of  decomposition  have  developed  in  the 
wound  we  will  endeavor  to  accomplish  an  aseptic  result  by 
thorough  disinfection.  Applications  of  solutions  of  chlo- 
ride of  zinc  (Socin,  /.  c.)  will  be  particularly  in  place,  as  has 
been  mentioned.  If  the  effort  does  not  succeed,  the  hope  of 
securing  an  aseptic  termination  must  be  discarded.  We 
must  endeavor,  then,  to  limit  as  much  as  possible  the  pro- 
cesses of  decomposition  and  their  extension  in  the  wound. 
We  will  then  order  antiseptic  irrigations  with  solution  of 
salicylic  acid,  with  acidulated  clay  with  acetic  acid,  with 
chloride  of  zinc  and  other  metallic  salts  in  combination,  and 
extensive  application  of  cold.  The  antiseptic  fluids  are  to 
be  cooled  either  by  insertion  into  vessels  containing  ice  or 
freezing  mixtures,  or  by  irrigating  the  shaved  head  drop  by 
drop,  while  it  is  enveloped  in  ice-bags.  The  ice-bags  may 
lie  upon  compresses,  which  are  maintained  moist  by  the 
fluid  which  is  used  for  irrigation. 

A  further  object  of  the  application  of  ice  is  to  reduce  or  re- 
lieve appearances  of  neuro-paralytic  cerebral  hyperemia, 
which  results  upon  the  production  of  reflex  vascular  con- 
traction, the  manifestations  of  brain  pressure,  especially  the 
depression  of  the  sensorium,  even  sopor.  Futhermore  the 
application  of  ice  is  particularly  efficacious  in  depressing 
the  temperature  in  whatever  septic  fever  there  may  be,  and 
especially  in  depressing  the  local  temperature.  Pirogoff,* 
when  in  the  Caucasus,  applied  ice  with  intercurrent  cold 
douches  to  the  head  in  gun-shot  wounds  to  that  part.  Stro- 
meyer,f  has  well  advocated  this  treatment,  and  justly 
showed  that  they  render  venesection  in  injuries  to  the  head 
unnecessary. 

But  there  are  cases  in  which  venesection  is  absolutely  re- 
quired. If  our  patient  be  robust  or  plethoric,  as,  for  in- 
stance, a  vigorous  soldier  would  be,  and  if  a  high-fever 
temperature  with  a  remarkably  slow  and  hard  pulse,  and  if 
respiration  be  superficial,  difficult,  or  even  irregular,  then 
we  will  follow  Pirogoff's  advice  and  proceed  to  venesection, 
which  may  be  repeated  in  case  the  appearances  return.  In 
children  and  in  debilitated  persons  venesection  must  be  sub- 
stituted by  local  depletion. 

The  influence  of  venesection  is  easily  comprehensible. 
When  evidences  of  brain  compression  exist  in  consequence 

*  Pirogoff,  Grundziige  der  allgem.  Kriegschirurgie.     Leipzig,  1864. 
■j-  Stromeyer,  Maximen  der  Kriegsheilkunst.   Hanover,  1861,  p.  405. 


SURGICAL  EMERGENCIES.  1 75 

of  inflammatory  hyperemia,  or  even  of  inflammatory  oedema 
with  impediments,  especially  to  the  arterial  supply,  a  vene- 
section will  act  principally  by  facilitating  the  venous  out- 
flow, upon  reduction  of  the  arterial  stream  in  removal  of 
the  obstacles  which  lie  in  the  compressed  capillary  regions. 
In  those  cases  where  the  cerebral  hyperemia  rests  upon  a 
paresis  of  the  arterial  walls,  venesection,  by  reducing  the 
amount  of  the  blood  and  by  reducing  the  fullness  of  the 
heart,  brings  about  a  reduction  of  volume  of  the  relaxed 
vascular  regions.  Thereby  the  intracranial  pressure  is 
reduced,  and  the  arterial  circulation  of  the  brain  will  be 
correspondingly  increased  through  the  relief  of  compressed 
districts. 

Similarly  we  must  explain  the  action  of  venesection  in 
apoplexia  (sanguinea)  cerebri,  in  robust  individuals  in 
which  it  has  long  been  proven  and  famed. 

Venesection  is  contra-indicated  in  weak,  delicate,  pale 
patients,  or  in  such  as  have  suffered  losses  of  blood,  or 
when  there  be  weakness  of  the  heart. 

The  third  important  helps  which  must  be  applied  in  man- 
ifestations of  compression  of  the  brain,  as  well  as  in  general 
sepsis,  is  the  use  of  purgatives,  rarely  in  the  form  of  dras- 
tics (calomel,  with  jalap)  when  a  rapid  action  is  desired. 
Saline  purgatives  are  more  recommendable.  The  patient 
maybe  given  either  one  to  two  tablespoonfuls  of  Glauber's 
salts  (natr.  sulfuricum)  or  Karlsbad  salt  (sal.  therm.  Caro- 
linens.  fact.)  dissolved  in  lukewarm  water,  which,  when  the 
patient  is  unconscious,  may  be  poured  directly  into  the 
stomach  through  the  oesophageal  catheter. 

The  action  of  purgatives  must  be  explained  by  the  pro- 
fuse intestinal  secretion  facilitating  the  elimination  of  septic 
matters  and  intensifying  the  lymphatic  flow,  and  with  it  the 
absorption  of  the  cerebro-spinal  fluid. 

We  must  consider  still  another  means  which  has  often 
manifested  its  saving  powers  in  diffuse  septic  processes, 
especially  of  the  serous  cavities,  of  the  peritoneum,  of  the 
pleura,  of  the  pericardium,  and  also  in  diffuse  meningitis. 
It  is  mercury,  which  may  best  be  employed  in  the  form  of 
inunctions  of  ung.  cinereum  (each  hour  or  two  one  or  two 
grams  are  rubbed  into  various  parts  of  the  body  succes- 
sively) pushed  as  far  as  the  production  of  acute  mercurial- 
ism.  Stromeyer  (/.  c.)  considered  the  appearance  of  saliva- 
tion as  a  frequent  sign  of  salvation.  Though  we  can  but 
surmise  how  and  in  what  form  mercury  is  absorbed  into  the 


176  SURGICAL  EMERGENCIES. 

organism  (Lassar*)  we  may  follow  the  practical  experiences 
which  have  been  attained  in  septic  processes  (Guthrie,  Mal- 
gaigne,  Traube)  and  apply  this  remedy  in  severe  cases;  and 
we  will  occasionally,  though  seldom,  achieve  life-saving 
results. 

It  is  self-evident  that  besides  antiseptic  irrigation,  appli- 
cation of  ice,  purgatives,  and  inunctions  of  gray  ointment, 
that  we  must  provide,  beyond  all,  for  free  outflow  of  the 
secretions  of  the  wound.  For  this  purpose  we  will  ofttimes 
require  dilatation  of  the  wound,  removal  of  bone-splinters, 
enlargement  of  the  opening  in  the  bone,  with  the  trephine 
or  the  chisel,  in  recent  injuries.  Only  when  fever  and  swel- 
ling of  the  wound  are  present  we  must  avoid  much  inter- 
ference, because  each  mechanical  irritation  may  aggravate 
the  condition  of  the  wound  and  may  facilitate  the  distribu- 
tion of  septic  matter. 

Notwithstanding  all  this,  whenever  septic  processes  occur 
in  complicated  injury  to  the  skull,  we  will  achieve  but  few 
good  results,  despite  all  of  our  cares.  The  limit  of  power 
of  our  therapeutic  measures  since  time  immemorial  is  best 
proven  by  the  officiousness  with  which  it  was  customary  to 
assault  and  torture  those  whose  heads  had  been  injured. 
Whenever  we  meet  such  officiousness  in  medicine  it  is  an 
evidence  of  limited  knowledge  and  small  ability.  We  owe 
the  simplification  of  the  treatment  in  the  above  sad  condi- 
tions, to  experimental  investigations  which  gave  us  the  first 
clear  clues  to  the  character  of  the  processes  which  occur  in 
disturbances  to  so  complicated  an  apparatus  as  is  the 
brain. 

More  favorable  results  are  obtainable  in  circumscribed 
accumulations  of  pus  within  the  brain,  in  limited  cerebral  ab- 
scesses, but  these  favorable  results  obtain  only  under  definite 
fortunate  conditions.  Primarily,  the  condition  must  not  be 
one  of  diffuse  purulent  phlegmon  of  the  arachnoid  or  sub- 
arachnoid. Secondly,  the  chances  are  more  in  favor  for 
opening  abscesses  which  occupy  a  superficial  position  over 
those  wkich  are  more  deeply  seated.  Thirdly,  the  diagnosis 
of  the  site  in  which  the  abscess  is  formed  must  be  firmly 
established.  Even  now  this  point  is  attended  with  great 
difficulties. 

Whenever,  in  injuries  to  the  head,  high  fever  is  associated 

*  Lassar,  Ueber  den  Zusammenhang   der   Hautresorption  und  Albu- 
minuric    Virchow's  Archiv.,  Bd.  77. 


SURGICAL  EMERGENCIES.  1 77 

With  chills,  cephalagia,  depression  of  the  sensorium,  etc., 
and  wherever  pus  wells  out  between  the  bone  fragments,  we 
do  not  hesitate  to  offer  a  free  exit  to  the  pus  by  removal  or 
elevation  of  the  pieces  of  bone  which  slop  the  opening. 
These  are  found  but  seldom  between  the  dura  mater  and 
the  bone,  as  Pott  assumed  to  be  the  rule.  We  find  this 
condition  only  when  a  decomposing  extravasation  of  blood 
lies  between  the  dura  mater  and  the  bone.  Ordinarily,  the 
pus  or  the  puriform  detritus  originates  from  the  brain-sub- 
stance itself.  The  dura  mater  is  occasionally  wedged  into 
the  osseous  space,  and  appears  over  the  abscess  in  either  a 
normal  condition  or  crushed  and  suffused  with  blood,  or 
discolored  and  mortified.  Or  pus  may  crowd  out  through 
slits  or  holes  in  the  dura  mater.  In  both  cases  the  dura 
mater  must  be  freely  slit,  the  abscesses  emptied  and  washed 
out  with  antiseptic  solutions.  It  finally  must  be  drained 
according  to  the  general  rules  of  oncotomy. 

The  diagnosis  of  an  abscess  is  much  more  difficult  when 
it  develops  behind  an  intact  cranial  bone.  Then  the  abscess 
can  be  opened  only  by  trepanning  the  skull  at  the  place 
where  the  abscess  is  presumed  to  be.  In  some  cases  this 
effort  has  proven  successful  (for  bibliography  see  Berg- 
mann,  /.  c,  pp.  294  and  295). 

After  the  execution  of  trephining  for  an  abscess  of  the 
brain  and  exposure  of  the  dura  mater,  the  usual  cerebral 
motions  which  are  observable  in  a  normal  brain,  and  which 
depend  upon  increased  temporary  repletion  of  blood,  are 
not  seen. 

The  cerebral  motions  are  partly  coincident  with  the  pulse 
and  partly  with  the  respiration.  Pulsatory  cerebral  motions 
are  isochronous  with  the  systole  of  the  heart,  and  depend 
upon  a  systolic  increase  of  blood  in  the  cerebral  arteries 
and  capillaries.  The  more  marked  respiratory  cerebral 
motions  occur  during  expiration. 

When  the  skull  is  intact,  the  brain,  which  is  full  of  blood, 
recedes  from  the  immobile  cranial  cover  towards  the  base 
of  the  skull,  because  the  cerebro-spinal  fluid  contained  in 
the  large  sub-arachnoid  space  of  this  region  can  most  easily 
be  displaced.  If  the  skull  be  perforated  at  any  place,  the 
brain's  excursions,  which  in  the  intact  skull  are  made  towards 
its  base,  will  approach  the  trephined  site,  which  has  become 
the  point  of  least  resistance.  Thus  the  brain  motions  be- 
come visible.  In  the  same  manner  we  see  them  at  thefon- 
tanelles  of  little  children  and  in  open  spaces  resultant  uuon 


178  SURGICAL  EMERGENCIES. 

craifial  fractures.  If  a  trephined  opening  be  closed  with  a 
glass  plate  the  brain  motions  are  no  longer  perceptible 
(Bonders).  This  led  to  the  erroneous  conclusion  that  brain 
motions  do  not  exist  in  the  normal  state. 

Brain  motions  are  often  absent  when  there  is  a  cerebral 
abscess.  Roser*  refers  this  to  a  close  attachment  of  the 
dura  mater  to  the  brain,  over  the  purulent  focus  and  not 
to  an  anaemic  condition  of  the  brain  beneath  the  trepan- 
ned orifice,  it  being  compressed  by  an  extravasation  of 
blood  or  an  exudation. 

After  evacuating  the  cerebral  abscess  prolapsus  cerebri 
frequently  supervenes  and  may  assume  extensive  dimen- 
sions if  inflammatory  cedema  or  encephalitis  occur.  Any 
interference  destined  to  the  replacement,  reduction  or  am- 
putation of  the  prolapse  is  reprobated.  The  most  rational 
course  would  be  to  protect  the  prolapsus  with  antiseptic 
dressings  in  case  it  becomes  mortified,  because  of  strangula- 
tion, and  threatened  with  disintegration.  Then  efforts 
should  be  made  to  confine  these  processes  by  sprinkling 
with  antiseptic  powders  (equal  parts  of  powdered  charcoal 
and  salicylic  acid),  by  painting  with  a  solution  of  chloride 
of  zinc,  by  antiseptic  irrigation,  etc. 

I  wish  to  call  your  attention  to  another  general  disturb- 
ance of  the  brain  functions  which  gives  a  similar  complexity 
of  symptoms  as  does  brain  compression,  without  the  occur- 
rence of  direct  contraction  of  the  cranial  cavity  or  severe 
brain  lesion.  I  refer  to  concussion  of  the  brain  —  commotio 
cerebri.  >, 

Hippocrates,  Galen,  Celsus,  and  later,  Ambroise  Pare, 
have  acyiered  to  this  conception  to  designate  disturbances 
of  the  brain  functions  which  result  from  violent  forces  being 
exerted  upon  the  skull,  as  in  blows,  falls  from  great 
heights  upon  the  head,  etc.,  and  manifest  themselves  in 
material  interruption  of  consciousness  or  at  least  an  ob- 
tunding  of  the  sensorium,  in  general  muscular  debility  and 
a  reduction  of  sensibility.  To  these  symptoms  there  are 
associated,  as  in  compressiontof  the  brain,  vomiting,  slow- 
ing of  the  pulse,  and  reduction  of  respiration  ;  in  severe 
cases  sopor,  coma  and  death  result.  Or  death  follows  im- 
mediately after  the  reception  of  said  traumatisms. 

Primarily,  all  of  those   conditions  which  are  established 

*  Roser,  Was  bedentet  das  Fehlen  der  Hirnbewegung  bei  blosslieg- 
ender,  Dura  Centralbl.  f.  Chir.  1875.     No.  11,  p.  161. 


SURGICAL  EMERGENCIES.  1 79 

in  complicated  injuries  of  the  head  must  be  segregated  from 
the  picture  of  the  entity  designated  as  concussion  of  the 
brain.  Nor  must  severe  crushings  of  the  brain,  with  ex- 
travasations of  blood  into  the  cranial  cavity,  or  into  the 
brain-substance  itself,  even  when  damage  to  the  bony  cranial 
shell  is  not  provable,  be  considered  in  this  connection. 
We  must  finally  eliminate  all  of  the  conditions  which  pre- 
vail when  great  violence  has  been  applied  to  the  skull,  and 
injuries  of  a  life-threatening  character  have  been  received 
in  other  organs,  such  as  occur  in  falls  from  great  heights. 
Carefully  made  autopsies  have  frequently  revealed  such 
injuries  in  cases  which  clinically  had  been  assumed  to  be 
concussion  of  the  brain,  with  rapid  fatal  issue.  This  has  oc- 
curred in  severe  injuries  and  extravasations  of  blood  in  and 
about  the  spinal  marrow  (Deville),  in  ruptures  of  the  heart 
(Prescott  Hewett),  in  a  tearing  into  the  kidneys  (Bergmann, 
/.  c),  or  in  diffuse  fatty  embolism  of  the  lungs,  kidneys, 
etc.  Recently  several  such  cases  have  been  described  oc- 
curring after  multiple  severe  bone-lesions,  elucidating 
enigmatical  conditions  found  after  bone-lesions  which  had 
a  rapid,  fatal  termination.*  Similar  results  are  attainable 
experimentally  by  moderate  injection  of  fluid  fat,  not  only 
directly  into  the  veins  and  the  heart,  but  also  by  injecting 
the  fat  into  peripheral  lymph-vessels  of  an  extremity. 

Only  such  cases  may  be  added  to  a  pure  picture  of  cere- 
bral concussion,  which  upon  careful  autopsy  of  the  entire 
cadaver,  present  no  severe  lesions  in  the  brain  or  other 
organs.  Slight  brain-crushings  are  often  found  in  concus- 
sion of  the  brain.  Though  similar  and  even  more  extensive 
brain-lesions  are  found  without  the  occurrence  of  symp- 
toms of  concussion  during  life,  the  slight  lesions  cannot 
be  considered  the  prime  cause  of  the  cerebral  commotio. 

Cases  of  pure  cerebral  concussion  occur  without  palpable 
or  provable  changes  in  the  cerebral  substance,  though  this 
has  been  frequently  placed  in  question.  The  experiments 
made  in  this  regard  have  yielded  undeniable  evidence  in 
support  of  the  assertion. 

The  views  which  prevailed  as  to  concussion  since  Littre'sf 

*  For  bibliography  compare:  Flournoy,  Contribution  a  l'etude  de  l'em- 
bolie  graisseuse.  Inaug.-Diss,  Strassburg,  1878;  Wiener,  Wesen  und 
Schicksal  der  Fettembolie,  Habilit-Schrift,  Breslau,  1879;  and  Scribla, 
Untersuchungen  iiber  Fettembolie,  Deutsche  Zeitschrift  f.  Chir.  Bd.  XII., 
Heft.  1  and  2. 

f  Littre,  Histoire  de  l'Acad.  Royale  des  Sciences,  1705,  p.  54. 


180  SURGICAL  EMERGENCIES. 

time,  as  to  a  quaking  or  succussion  through  the  brain-mattef, 
in  consequence  of  the  communication  of  the  undulations 
caused  by  the  traumatism  applied  to  the  skull,  and  trans- 
ferred to  the  brain,  through  it,  have  been  entirely  refuted  by 
Gama's  experiments,  which  were  considerably  modified  by 
the  investigations  of  Nelaton,  Alquie*  and  Fischer.f 

Beck  (/.  c.)  calls  attention  to  the  fact  that  the  most  marked 
disturbances  in  concussions  of  the  brain  point  to  certain 
regions  of  the  brain  and  their  affections,  thus,  especially,  the 
medulla  oblongata.  He  found  extravasations  of  blood  in 
the  fourth  ventricle  in  concussion  of  the  brain  artificially 
produced,  while  WestphalJ  wHo  made  experimental  blows 
on  the  skull,  reports  numerous  small  haemorrhages  scattered 
in  the  spinal  marrow.§ 

Capillary  extravasations  of  blood  scattered  over  the  en- 
tire brain  have  been  observed  clinically.  Sometimes  they 
are  entirely  absent. 

When  the  entity  of  concussion  is  separated  into  an  affec- 
tion of  individual  brain-centres  it  becomes  evident  that 
probably  the  force  applied  primarily  affects  certain  centres, 
for  instance,  those  of  the  vascular  nerves,  those  of  the  heart 
and  respiration,  and  that,  above  all,  the  primary  disturbance 
of  circulation  produces  a  disturbance  of  nutrition  of  the 
other  centres,  whether  by  arterial  anaemia,  venous  hyperae- 
mia,  or  of  both  in  succession.  Various  reasons  can  be  cited 
for  this. 

Above  all,  rapid  recovery  in  certain  cases  of  concussion 
seems  to  prove  that  there  can  hardly  be  a  material  change 
within  the  brain-mass,  but  that  it  can  have  been  affected  by 
only  a  transitory  disturbance  of  nutrition.  Beck  (/.  c.) 
found,  upon  removing  the  cranial  cover  in  animals  in  whom 
clear  symptoms  of  concussion  of  the  brain  were  manifest, 
that  the  brain  was. very  pale  and  all  of  the  vessels  were 
strongly  contracted.     A  similar  condition  was   proved  by 

*  Alquie.  Etude  Clinique  et  Experimental  de  la  Commotion  Trauma- 
tique,  etc.     Gaz.  Med.  de  Paris,  1865. 

f  Fischer,  Ueber  die  Commotio  cerebri,  Samml.  Klin.  Vortrage  von 
R.  Volkmann,  1871,  No.  27. 

X  Westphal.  Bed.  Klin.  Wochenschr.,  1871,  p.  461. 

§  See  also  Duret.  Notes  sur  la  Physiologie  Pathologiquedes  Trauma- 
tismes  Cerebraux.  Gaz.  Med.  de  Paris.  1877.  Nos.  40,  59  and  61.  In  forced 
increase  of  intracranial  pressure  Duret  found  haemorrhages  into  the  walls 
of  the  several  ventricles,  especially  the  fourth  ;  into  the  aqueduct  of  Syl- 
vius, etc.,  which  he  combines  with  the  disturbances  of  the  various  brain 
functions  observed  in  concussion. 


SURGICAL  EMERGENCIES.  l8l 

iBergmann  (/.  c,  p.  213)  in  the  background  of  the  eye  of 
rabbits  with  profound  cerebral  commotion.  Furthermore, 
all  of  the  records  of  post  mortems  made  in  those  dead  of 
cerebral  concussion  show  great  repletion  of  the  veins  of  the 
brain  and  those  of  its  envelopments. 

Fischer  (/.  c.)  compared  the  action  of  traumatism  in  a 
concussion  of  the  brain  to  the  effect  of  the  experiments  of 
Goltz,  made  by  striking  a  frog.  A  rapid  spasm  of  the 
vascular  system  after  primary  irritation  of  the  vascular 
nerve-centers  is  said  to  follow  their  paralysis,  with  a  gene- 
ral vascular  paralysis.  The  difference  between  the  experi- 
ments in  which  a  blow  was  employed  and  the  gradual  influ- 
ence of  a  great  power  upon  the  skull,  may  be  solved  by  the 
fact  that  in  traumatism  of  the  head  the  sudden  crowding 
of  the  cerebro-spinal  fluid  and  of  the  whole  brain,  suffices 
as  a  direct  mechanical  irritation  to  produce  a  rapid  excite- 
ment followed  by  a  continned  paralysis  of  the  brain-centres 
while  in  experimenting  with  blows  on  the  belly,  oft-repeated 
(reflected  ?)  irritation  would  be  requisite. 

The  primary  arterial  cerebral  anaemia  is  followed  by  hy- 
peremia in  connection  with  the  vascular  paralysis,  which, 
however,  as  has  been  explained,  under  compression  of  the 
brain,  again  secondarily  retards  the  arterial  flow  by  the 
interpolation  of  large  impediments  to  the  capillary  circula- 
tion. Furthermore,  paralysis  of  the  vascular  nerve-centres 
produces  a  dilatation  of  the  vessels  in  all  of  the  regions  of 
the  body  with  engorgement  of  blood  in  them,  which  im- 
plies a  deep  sinking  of  the  blood-pressure.  To  the  brain 
in  which  the  arterial  flow  is  retarded,  this  means,  further- 
more, that  the  arterial  blood  flows  through  its  various 
regions,  not  only  more  slowly,  but  also  in  lesser  quantities. 

Koch  and  Filehne*  in  a  similar  manner  endeavored  to 
derive  the  symptoms  of  concussion  of  the  brain  from  a 
direct  mechanical  affection  of  all  the  brain-centres.  Cer- 
tainly the  affection  of  the  vasomotor  centres  plays  a  princi- 
pal part  in  this  connection.  We  also  see  in  cerebral  con- 
cussion disturbances  of  those  centres  which  are  most  suscep- 
tible to  anomalies  of  nutrition,  that  is,  disturbances  in  the 
various  centers  lying  within  the  cerebral  cortex,  where  they 
are  most  strongly  marked. 

The  fact  that  such  disturbances  of  nutrition  of  the  brain- 

*  Koch  and  Filehne,  Ueber  Commotio  cerebri,  Verhandl.  d.  deutschen 
Gesellsch.  f.  Chir.,  1874,  HI.  Congr.  Grossere  Vortrage,  p.  10. 


1 82  SURGICAL  EMERGENCIES. 

centres  really  occur  in  concussion  of  the  brain  is  again 
shown  very  clearly  in  the  cases  which  terminate  in  recovery. 
In  these,  each  of  the  functions  of  the  brain  was  restored  as 
slowly,  as  after  profound  chloroform  narcosis,  in  which  a 
dangerous  asphyxia  existed.  I  would  call  your  attention 
particularly  to  the  manifestation  which  Bohm*  described 
in  his  reports  of  animals  which  he  had  chloroformed  almost 
to  death  and  which  he  details  as  manifestations  after  re- 
covery from  apparent  death  ("  Erscheinungen  nach  geho- 
benem  Scheintod ").  This  analogy  is  particularly  note- 
worthy because  you  know  how  deeply  the  blood-pressure 
can  sink  for  a  long  time   in  dangerous  chloroform  narcosis. 

We  distinguish,  in  cases  of  cerebral  concussion  which  do 
not  terminate  fatally,  between  light  cases  and  severe  ones. 
In  both,  the  principal  symptom  is  unconsciousness  lasting 
for  a  lesser  or  greater  length  of  time. 

In  the  lighter  cases  the  patient  breaks  down  with  a  sen- 
sation of  giddiness,  glittering  before  the  eyes,  and  whirring 
in  the  ears.  His  face  becomes  pale,  the  eyes  become  fixed 
and  non-responsive.  The  respiration  appears  flat,  the  pulse 
filiform  and  barely  perceptible.  Soon  the  patient  recovers 
and  complains  only  of  headache,  debility,  languour  and 
tingling  in  the  ears.  Sometimes  various  subsequent  dis- 
turbances of  the  motor  sphere  appear,  thus  as  in  the  move- 
ments of  the  eye  ;  there  also  may  be  stammering  or  at 
least  difficult  articulation.  Permanent  disturbances  of  the 
various  co-ordinate  movements,  as  grasping,  etc.,  are  par- 
ticularly worthy  of  attention.  Diabetes  mellitus  and  in- 
sipidus, and  albuminuria  have  been  observed  after  concus- 
sions of  the  brain. 

The  symptoms  of  severe  cases  of  concussion  of  the  brain 
are  more  complicated.  Unconsciousness  is  absolute;  the 
injured  person  does  not  respond  to  strong  irritations.  The 
pupil  contracts  but  slowly  upon  the  approach  of  light,  but 
frequently  swallowing  takes  place  upon  fluids  being  poured 
in.  The  features  are  deadly  pale  and  collapsed.  The  body 
soon  becomes  quite  cool.  The  pulse  is  intermittent,  small, 
and  often  slow.  Urine  and  faeces  are  retained  or  are  passed 
unconsciously.  Vomiting  often  follows  later  on.  After 
the  lapse  of  hours  or  days  an  improvement  occurs.  Re- 
spiration becomes  deeper,  the  heart  and  pulse  beat  more 

*  Bohm.  Ueber  Wiederbelebung  nach  Vergiftung  und  Asphyxie, 
Archiv.  f.  experim.  Pathol,  und  Pharmakol.,  Bd.  VIII.,  pp.  68  to  101. 


SURGICAL  EMERGENCIES.  1 83 

fully  and  strongly,  the  bodily  temperature  rises,  voluntary 
motions  again  are  made,  and  finally  consciousness  returns. 

Most  frequently  the  general  depression  is  followed  by  a 
stage  of  excitement.  The  temperature  of  the  skin  rises, 
the  pulse  becomes  hard  and  frequent,  the  face  is  flushed, 
the  pupils  are  contracted  and  the  eyes  glisten. 

Furthermore,  when  true  meningitic  manifestations  are 
developed,  then  a  pure  concussion  has  not  occurred,  but  a 
complication  with  evident  injury  to  the  skull  and  brain  has 
taken  place.  We  must  assume  the  same  when  the  comatose 
condition  continues  very  long,  or  when  the  sopor  becomes 
more  profound,  also  when  convulsions  or  paralyses  of  cer- 
tain regions  occur.  This  issue  has  been  noted  particularly  in 
concussion  with  co-incident  fracture  of  the  base  of  the  skull. 

Though  the  patient  recovers  rapidly  after  concussion  of 
the  brain  he  may  by  no  means  be  removed  from  medical 
supervision.  Sometimes  serious  manifestations  occur  later. 
Sudden  symptoms  of  compression  of  the  brain  may  appear 
when  the  extravasations  of  blood  within  the  skull  become 
enlarged,  or  when  a  not  diagnosable  crushing  of  the  brain 
gives  rise  to  the  appearance  of  general  inflammatory  pro- 
cesses in  the  brain  and  its  coverings. 

The  treatinent  of  cerebral  concussion  must  be  purely 
symptomatic.  The  depression  of  the  blood-pressure  re- 
quires the  application  of  means  which  would  elevate  it, 
among  which  irritations  to  the  skin  play  an  important  part. 
Perhaps  autotransfusion,  by  depressing  the  head  lower  than 
the  body,  may  prove  efficacious.  Repeated  subcutaneous 
injections  of  ether  (a  Pravaz  syringe-full,  about  a  gram, 
at  a  time)  have  been  recommended.  Large  doses  of  musk 
should  be  given  internally  when  the  patient  can  swallow. 
Particular  provisions  should  be  made  against  the  reduction 
of  the  bodily  temperature  by  enveloping  it  in  warm  cloths, 
and  the  application  of  hot  bottles  to  the  body  of  the  pa- 
tient as  well  as  long-continued  warm  baths. 

Beyond  all,  the  hair  should  be  cut  or  the  head  shaved, 
and  carefully  examined  for  whatever  injuries  there  maybe. 
If  later  on  inflammatory  manifestations  occur  they  must  be 
treated  as  has  been  detailed  above. 

In  the  discussion  of  therapeutic  measures  in  contractions 
of  the  space  within  the  skull,  such  as  are  dangerous  to  life, 
and  in  injuries  to  the  skull,  we  have  noted  that  trephining 
the  cranium  has  given  us  some  indication  -  which  incite  us  to 
devote  some  remarks  to  this  operation. 
1 


1 84  .  SURGICAL  EMERGENCIES. 

For  centuries  the  applicability  or  non-applicability  of  this 
operation,  which  was  well  known  and  practised  by  the 
oldest  nations,  was  widely  discussed.  The  most  extreme 
views  prevail  as  to  the  applicability  of  trepanning  in  all 
complicated  injuries  to  the  head  (prophylactic  trepanning 
— Pott),  while  others  have  advocated  its  complete  elimina- 
tion from  surgical  practice  (Textor,  Dieffenbach,  Malgaigne, 
Stromeyer). 

In  general  we  find  that  the  more  complete  the  surgical 
school  the  rarer  the  trepan  was  employed.  Even  those  who 
saw  their  patients  die  with  injuries  to  the  head,  notwith- 
standing trepanning  more  frequently,  yet  in  consequence  of 
it  they  rescinded  more  and  more  from  the  employment  of 
the  operation. 

At  all  events  we  may  consider  prophylactic  trepanning  in 
recent  injuries  to  the  head  as  definitely  set  aside.  We  sub- 
stitute it  by  carefully-executed  antiseptic  cleansing  of  the 
wounds  and  subsequent  antiseptic  occlusion,  just  as  we 
have  ceased  to  make  primary  resections  of  the  joints  in  re- 
cent injuries  to  them,  as  was  done  especially  to  favor  con- 
ditions to  guard  against  the  inroads  which  suppuration, 
established  within  the  synovial  cavities,  would  make.  This 
process  usually  established  itself  when  antiseptic  precau- 
tions are  not  employed. 

Exploratory  trepanning  for  the  purpose  of  extracting 
foreign  bodies,  or  to  find  abscesses  which  had  been  formed 
within  the  brain  and  evacuated,  has  recently  suffered  much 
limitation.  In  foreign  bodies  we  will  trephine  only  when 
they  are  wedged  into  the  cranial  parietes  and  can  not  be 
removed  without  the  bony  substance  that  surrounds  them 
(such  as  knife-blades,  ramrods,  etc.,  which  are  wedged  into 
the  bone).  Exploration  for  foreign  bodies  that  are  not 
visible,  especially  bullets,  is  reprehensible  as  long  as  there 
are  no  cerebral  manifestations  indicating  the  presence  of 
the  foreign  body,  or  inflammations  or  suppurations  pro- 
duced by  it.  The  absence  of  a  wound  of  exit  in  gun-shots 
to  the  head  does  not  justify  the  assumption  that  the  bullet 
lies  within  the  cranial  space.  Despite  the  firm  assertions 
of  the  patient  or  of  other  witnesses,  the  force  of  the  ball 
may  have  become  spent  after  the  concussion  and  produc- 
tion of  the  depression  in  the  bone,  and  may  have  simply 
fallen  to  the  ground.  As  to  the  value  of  exploratory  tre- 
phining in  abscess  of  the  brain  we  have  repeatedly  expressed 
ourselves.     A  more  concise  knowledge  of  the  localization 


SURGICAL  EMERGENCIES.  1 85 

of  the  individual  brain  functions  will  give  us  definite  points 
of  departure  in  the  future. 

Therefore  we  will  proceed  to  trephining,  that  is,  to  the 
removal  of  a  firm  piece  of  bone  from  the  continuity  of  the 
cranial  roof;  first,  for  the  purpose  of  enlarging  the  space 
in  the  bone  through  which  to  extract  splinters  of  bone  or 
foreign  bodies  that  are  difficult  to  move  or  grasp;  secondly, 
for  the  purpose  of  ligating  the  injured  middle  meningeal 
artery  in  case  it  cannot  be  tied  in  the  wound;  thirdly,  to 
remove  blood  from  the  skull  or  masses  of  pus  from  the 
brain  substance. 

When  there  is  no  fracture  of  the  skull  we  trephine  only  to 
remove  such  a  piece  of  bone  into  which  a  foreign  body  has 
been  firmly  wedged;  furthermore,  for  the  purpose  of  ligat- 
ing the  middle  meningeal  artery  when,  notwithstanding 
slight  damage  to  the  bone  there  are  clear  symptoms  of 
haemorrhage  from  this  artery,  and,  finally,  for  the  purpose 
of  evacuating  abscesses  which  have  been  diagnosticated  in 
certain  regions  of  the  brain. 

We  will  begin,  in  describing  the  typical  procedures,  by 
those  of  bori?ig  out  the  bony  disc  from  the  intact  cranial  arch. 
We  alluded  to  it  in  discussing  the  procedures  for  ligating 
the  middle  meningeal  artery. 

After  splitting  the  skin,  the  soft  parts,  and  the  periosteum, 
we  arrive  immediately  upon  the  bone,  which  we  free  by 
levering  off  the  periosteum  to  a  sufficient  extent.  The  disc 
of  bone  is  bored  out  by  means  of  the  crown  of  the  trepan; 
a  metal  cylinder,the  under  margin  of  which  is  provided  with 
saw-teeth.  Its  upper  closed  end  is  continued  in  a  hollow  axle 
into  which  a  rotary  curved,  or  a  diagonal  handle  is  fastened 
by  means  of  which  the  crown  can  be  given  a  rotary  motion 
upon  its  axis.  The  first  combination  is  called  the  arched 
trepan  (Bogen  trepan),  when  a  diagonal  handle  is  used  the 
combination  represents  the  trephine  or  hand-trepan.  The 
cylindrical  saw  might  slip  when  placed  upon  the  arched 
surface  of  the  cranial  roof,  therefore  these  instruments 
carry  within  their  cylinder  a  spear,  called  the  pyramid, 
which  may  be  moved  upwards  or  downwards.  This  pyra- 
mid is  allowed  to  project  over  the  free,  toothed-edge  of  the 
crown  of  the  trepan,  and  is  inserted  into  a  small  hole  which 
has  previously  been  made  by  the  perforating  trepan  (a  hand 
trepan  with  a  heart-shaped  point)  or  with  a  gimlet.  If  the 
spear  penetrates  sufficiently  deep  into  the  hole  prepared 
for  it,  the  teeth  of  the  crown  of  the  trepan  gradually  en- 


1 86  SURGICAL  EMERGENCIES. 

croach  upon  the  bone,  forming  a  disk,  which  is  to  be 
removed  within  the  furrow  which  the  saw-teeth  produce. 
Then  the  pyramidal  spear,  within  the  cylinder  of  the 
trepan,  is  drawn  upward  so  as  to  facilitate  further  sawing. 
Before  the  bony  disc  has  become  entirely  movable  a  screw 
must  be  fastened  into  the  central  hole  to  form  a  sort  of 
handle  with  a  corresponding  quadrangular  opening  at  the 
upper  end  of  the  screw.  The  hook  or  lever  with  the  screw 
bear  the  collective  name  of  Tirfonds.  In  emergencies  this 
may  be  substituted  by  a  pointed  elevator,  or  a  chisel,  to  be 
used  as  levers,  or  Bruris  sequestrwn pliers.  When  every  pre- 
paratory production  of  a  hole  within  the  bone  disc  is  impos- 
sible, as  when  the  middle  of  the  disk  is  a  movable  fragment 
of  bone  which  lies  within  the  depression,  slipping  of  the 
crown  of  the  trepan  must  be  prevented  by  pressing  metal 
rings  with  lateral  handles  (crown  holders)  upon  the  skull, 
and  rotating  the  crown  of  the  trepan  within  their  open 
space.  Perforated  discs  of  pasteboard,  leather,  and  wood 
have  been  used  for  the  same  purpose. 

During  the  sawing  a  sound  should  be  inserted  from  time 
to  time  in  the  furrow,  to  elicit  whether  it  is  equally  deep 
in  all  its  parts.  When  this  is  not  the  case,  further  motions 
of  the  crown  of  the  trepan  must  be  depressed  more  towards 
the  side  at  which  it  has  not  as  yet  penetrated  as  deeply  as 
it  did  on  the  other.  This  is  one  of  the  reasons  for  ihepref- 
erence  of  the  hand  trephine  over  the  arched  trepan,  because  the 
former  allows  perforation  with  greater  delicacy.  If,  after  the 
disc  of  bone  has  been  removed,  the  trephined  orifice  shows 
a  rough  margin  or  projecting  bony  points,  especially  to- 
wards the  cranial  cavity,  they  must  be  smoothed  off  with 
an  appropriate  instrument  (linsenmesser :  lentil-knife),  a 
chisel,  the  sides  of  which  are  sharpened,  but  the  point  of 
which  is  blunted  by  a  flat,  lentil-shaped  button,  which  oc- 
cupies a  diagonal  position  to  it.  The  button  is  placed  be- 
tween the  bone  and  the  dura  mater,  while  the  knife  is  ro- 
tated upon  its  axis  and  its  sharp  edges  pressed  against  the 
uneven  bony  margin,  so  as  to  cut  it  or  scrape  it  smooth. 
Luer's  rongeurs  are  very  handy  for  the  removal  of  project- 
ing points  of  bone,  or  for  rounding  off  toothed  projections 
within  the  margin  of  a  space  in  the  bone.  It  were  well  to 
have  several  of  these  instruments,  of  various  sizes,  on  hand. 
For  the  removal  of  splinters  of  the  inner  plate  which  have 
slipped  under  the  margin  of  the  trepanned  opening,  be- 
tween the  dura  mater  and  the  bone,  Bruns'  long  pincettes, 


SURGICAL  EMERGENCIES.  1 87 

with  doubly  crossed  legs  and  scoop-shaped  ends,  are  very- 
useful.  These  forceps  are  either  straight  or  bent  to  an 
angle  on  their  flat  surfaces. 

Wherever  the  purpose  is  not  to  produce  an  opening  in 
the  intact  cranial  roof,  but  to  enlarge  or  round  off  trauma- 
tic defects  in  the  bone,  as  in  splintered  fractures,  etc.,  the 
us«  of  the  hammer  and  chisel  deserve  preference  over  tre- 
phining instruments,  as  being  more  conveniently  man- 
aged  (Roser*).  It  is  equally  recommendable  to  re- 
move foreign  bodies  which  are  wedged  into  the  cranial 
bone  (projectiles,  knife-blades,  etc.),  with  a  chisel,  a  safer 
procedure,  which  entails  less  injury  than  does  the  removal 
of  a  disc  of  bone.  The  fear  of  the  production  of  fissures 
by  the  use  of  the  chisel  is  as  little  justifiable  as  is  the  fear 
that  the  use  of  the  chisel  would  produce  necrosis  of  the 
margins  of  the  solution  of  continuity.  The  chisel  which  is 
employed  should  be  preferably  sharpened  on  one  side, 
such  as  sculptors  use,  instead  of  the  wedge-shaped,  thin 
blade  which  is  usually  employed.  Experiments  made  on 
other  bones  of  the  skeleton,  of  which  large  numbers  are 
now  recorded,  because  of  the  increasing  frequency  with 
which  osteotomies  and  similar  operations  are  now  made, 
have  also  contributed  their  share  to  relieve  the  prejudice 
against  the  use  of  the  chisel,  and  have  established  its  un- 
qualified preference  over  the  saw.  The  long  bones  have  also 
been  trephined  through  the  diaphyses  in  infectious  osteo- 
myelitis, so  as  to  wash  out  the  ichorous  medullary  substance 
through  the  trephined  opening,  to  disinfect  it,  and  to  drain 
the  osseous  canal. 

Trephined  openings  heal  but  slowly,  as  do  all  fractures 
and  fissures  of  the  cranial  roof.  According  to  Kosmowski's  f 
experiments,  the  principal  proliferation  proceeds  from 
the  opened  medullary  spaces  of  the  diploe.  The  new 
formed  (osteoid)  connective  tissue  yields,  directly,  bony 
substance,  which  radiates  from  the  periphery  of  the  hole 
into  the  fibrous  connective  tissue,  which  closes  the  open- 
ing.    This,  however,  occurs  in  but  a  defective  way. 

In  the  beginning,  the  brain  crowds  the  dura  mater  into 
the  opening,  and  manifests  clearly  perceptible  pulsations. 
But  gradually  the  connective  tissue  cicatrix   in  the  trepan- 

*  Roser,  Archiv.  f.  Heilkunde,  1867,  p.  553. 

f  Kosmowski,  Heilung  von  Trepanationswunden,  St.  Petersburg,  1871 
(in  Russia). 


188  SURGICAL   EMERGENCIES. 

ned  hole  becomes  so  firm  and  callously  tough  that  the 
brain-pulsations  are  not  transmissible  through  it,  although 
the  formation  of  bone  in  it  is  but  incomplete,  occurring 
only  in  the  form  of  bony  islets. 

In  larger  solutions  of  continuity  of  the  skull,  especially 
in  necrosis  of  the  bone  (for  instance  in  syphilis),  the  scar 
is  more  resilient,  allowing  perceptible  brain-pulsations  to 
persist  for  years.  Owing  to  the  danger  to  which  such 
patients  are  exposed  in  cases  of  repeated  traumatisms  to 
the  head,  they  are  ordered  to  wear  protectors,  which  have 
inserted  into  them  correspondingly  curved  and  padded 
metal  or  leather  plates,  to  cover  the  defect  in  the  bone  or 
the  hole  produced  by  the  trephine. 

It  is  said  that  efforts  to  heal  in  the  discs  which  had  been 
removed  have  succeeded  in  isolated  cases.  According  to 
the  experiments  of  J.  Wolff,*  success  in  this  regard  is 
materially  facilitated  when  a  bony  flap  is  lifted  up,  cover- 
like, and  its  base  allowed  to  remain  in  connection  with  the 
cranial  roof  by  periosteum,  and  subsequently  re-inserted 
into  the  opening.  This  procedure  has,  as  yet,  not  been 
practically  applied. 

*  J.  Wolff,  v.  Langenbeck's  Archiv.  Bd.  IV.,  p.  250,  u.  ft. 


SURGIGAL  EMERGENCIES.  189 


LECTURE  XII. 

Aids  in  accidents  to  masses  of  men. — Surgical  aid  in  war. — 
General  consideratio?is . — Objective  points  of  military  surgery. — ■ 
Task  of  each  individual  surgeon. — Information  requisite. — 
Leading  principles  in  military  practice. — The  battle-field. 
— Division  of  the  wounded  into  those  tvho  are  capable  and  those 
who  are  incapable  of  marching. — Places  for  immediate 
dressings. — Selection  of  place. — Refreshment  for  the  wounded. 
— Classification  of  injuries. — Provisional  arrest  of  dangerous 
hozmorrhages. — How  should  the  primary  dressing  be  made  ? — 
Antiseptic  compresses,  bandages,  cloths,  slings. — Splints,  their  im- 
provisation.— Stretchers. — Means  of  transport  from  the  battle- 
field.— Medical  staff. — Carriers  of  the  wounded. — The  place  of 
permanent  dressing. — Only  for  the  wounded  who  cannot  march. 
The  medical  staff  and  its  organization. — Organization  of  the 
sanitary  detachment.  —  Consulting  surgeons.  —  Assortment  of 
the  wounded. —  Tickets. —  The  diagnosis  cards  formerly  employed. 
— Dressings  for  those  to  be  immediately  removed. — Injuries 
belonging  to  this  class. — Form  of  dressing. — Drainage. — 
Course  and  contents  of  the  canal  of  the  shot-wound. — Splints, 
ready-made  and  improvised. — Means  of  transportation  from 
the  dressing-station  to  the  field-hospital,  to  the  depot,  and  to  the 
sanitary  train — Improvisation  of  these  means  of  transportation. 
— Injuries  in  which  operative  interference  is  requisite. — No  re- 
sections to  be  performed  at  the  dressing  station. — Injuries  ivhich 
cannot  bear  transportation. 

Gentlemen:  You  will  comprehend  that,  if  we  should  be 
required  to  compress  within  the  limits  of  a  single  lecture 
every  fact  of  value  for  your  work  as  military  surgeons,  no 
exhaustive  presentation  of  the  subject,  but  only  the  leading 
principles  in  their  general  outline,  could  be  set  forth.  It  is, 
however,  not  our  task  to  add  one  more  to  the  numerous 
works  on  military  surgery  to  which  the  last  two  belligerent 
decenniums  have  given  rise.  You  will  merely  obtain  in 
the  labor  of  the  surgeon  in  war  time  an  example  of  how 


I90  SURGICAL  EMERGENCIES. 

and  when  you  are  to  apply,  or  to  modify,  the  rules  for  assis- 
tance which  you  have  learned  to  employ  in  saving  the  life 
of  a  single  individual,  whenever  it  should  be  your  lot  to 
have  to  do  with  serious  conditions  occurring  among  larger 
bodies  of  men. 

A  glance  at  the  history  of  military  surgery  shows  that, 
among  various  nations,  greater  attention  began  to  be 
directed  to  the  care  of  the  wounded,  at  the  time  when  these 
nations  had  arrived  at  a  certain  rather  high  degree  of  civi- 
lization. 

In  regard  to  the  requisites  which  are  here  involved,  the 
closest  approximation  to  their  fulfilment  yet  made  was 
in  the  last  Franco-Prussian  war  (1870-71).  And  as  the 
final  result  of  all  labors  directed  to  this  end  two  problems 
have  originated,  whose  solution  must  be  sought  for  in  our 
future  way  in  history  by  every  possible  means,  if  we  wish 
to  attain  any  real  progress  in  the  domain  of  military 
surgery. 

The  first  problem  implies  the  task  of  combining  the  most 
earnest  endeavors  for  the  care  and  treatment  of  the 
wounded  in  war  time,  with  the  maintenance,  hitherto  neg- 
lected, of  the  hygiene  of  soldiers  in  time  of  peace. 

In  the  way  thus  marked  out,  Saxony  alone  has  out- 
stripped other  nations  by  the  establishment  of  the  Albert- 
opolis  in  Dresden,  thus  setting  an  illustrious  example.  The 
application  and  further  extension  of  the  results  thus  ob- 
tained must  be  left  by  civil  and  military  authorities  alike 
to  the  army  surgeons. 

For  you,  gentlemen,  who,  as  practising  physicians  in 
every-day  life  are  called  upon  to  act  among  greater  and 
smaller  communities  of  people,  the  second  problem  is  of 
far  greater  importance.  For  the  second  problem  depends 
upon  the  task  of  advantageously  organizing  the  volun- 
teer corps  of  nurses  for  the  wounded,  and  of  making 
them  serviceable  to  the  widest  possible  extent. 

Here  is  the  field  in  which  you,  as  scientific  experts  and 
advisers  of  the  self-sacrificing  multitude,  must  regulate  the 
correct  division  and  application  of  the  forces  at  your  com- 
mand. 

In  order  to  be  wholly  quit  of  these  claims  upon  you,  cer- 
tain prerequisites  are  necessary,  namely  : 

1.  Acquaintance  with  the  sanitary  establishment  of  the 
army  in  time  of  war.  As  is  evident,  we  cannot  here  enter 
upon  this  subject. 


SURGICAL   EMERGENCIES.  I9I 

2.  Acquaintance  with  the  duty  of  the  physician  in  time 
of  war,  either 

(a)  Upon  the  battle-field. 

(b)  At  the  place  for  immediate  dressing. 

!c)  At  the  field  hospital. 
d)  At  the  depots  and  in  the  hospital  at  home. 

3d.  Acquaintance  with  the  means  of  transportation  from 
the  battle-field  to  the  place  selected  for  temporary  dressing 
and  the  field-hospital,  from  there  to  the  depot,  and  from 
the  latter  home  (land,  water  and  railroad  transportation). 

Only  a  few  of  the  above  categories  can  form  the  subject 
of  a  more  intimate  inquiry. 

In  the  first  place,  it  appears  of  importance  to  establish 
the  general  standpoint,  which  can  serve  us  as  a  guide  to 
our  duty  as  physicians  in  war.  Briefly  summarized,  this 
is  as  follows: 

1.  Correct  division  of  labor  among  the  assistant  force. 

2.  Immediate  assortment  of  the  wounded,  according 
to  the  severity  of  their  injuries. 

3.  Rational  attention  to  the  immediate  shelter  and 
care  of  the  wounded.  (Removal  to  buildings,  sheds 
and  tents;  feeding.) 

4.  Immediate  dressing,  with  special  reference  to  the  sub- 
sequent antiseptic  treatment  and   to  transportation. 

4th.  Suitable  adaptation  of  matters  at  hand  (soldiers' 
clothes,  weapons,  furniture  in  dwellings,  vehicles  in  cities 
and  in  the  country,  etc.),  to  form  improvised  materials  for 
dressing,  lodging  and  transportation. 

After  the  above  remarks  it  will  be  clear  to  you  that  it  is 
the  work  expended  on  the  battle-field  and  at  the  place  of 
temporary  dressing  which  appears  the  most  important  and 
the  most  laborious.  Moreover,  it  requires  a  very  particu- 
lar consideration,  because  it  is  in  many  respects  so  different 
from  surgical  practice  in  times  of  peace. 

THE   BATTLE-FIELD. 

Here  the  task  for  the  sanitary  service  consists  in  the 
transportation  of  all  of  the  surviving  wounded  to  the  place  of 
immediate  dressing  or  to  the  field-hospital.  The  wounded, 
accordingly,  are  simply  to  be  separated  into  two  chief 
divisions. 

*  Knorr,  Ueber  Entwickelung  und  Gestaltung  des  Heeres-Sanitats 
wesens  d.  europaischen  Staaten.     Hanover,  1878  u.  1879.     6  Hefte. 


IQ2  SURGICAL  EMERGENCIES. 

(a)  Those  capable  of  marching,  to  be  transported  to 
the  field-hospital. 

(b)  Those  incapable  of  marching,  to  be  transported  to 
the  place  for  temporary  dressing. 

In  order  to  be  able  to  conduct  this  classification  upon  a 
large  scale,  certain  places  of  rendezvous  (places  for  dress- 
ings of  urgent  necessity)  should  be  located  upon  the  battle- 
field itself,  out  of  the  range  of  musket-fire,  if  possible,  and 
marked  by  the  sign  of  the  Geneva  Convention — a  red  cross 
on  a  white  field.  If  possible,  a  plot  of  ground  should  be 
chosen,  with  a  shady  group  of  trees,  perhaps,  too,  with  a 
brook  or  a  shed;  at  all  events,  a  place  should  be  selected 
where  a  tent  can  be  pitched  for  the  severely  wounded. 

The  first  duty  at  the  place  for  urgent  dressings  must  con- 
sist in  the  administration  of  cordials  and  stimulants  to  the 
wounded.  Next,  we  shall  have  to  direct  our  chief  care  to 
the  assortment  of  injuries  for  the  application  of  dressings. 
Of  operative  procedures,  the  only  one  which  can  come  into 
question  is  the  provisional  arrest  of  haemorrhages  of  suffi- 
cient magnitude  to  threaten  life. 

In  what  way  should  the  first  dressing  be  constructed, 
upon  the  field  of  battle? 

In  modern  warfare,  gun-shot  wounds  preponderate  over 
all  other  forms  of  injury.  Thus,  in  the  campaign  of  1866, 
the  wounds  in  the  Prussian  army*  of  13,202  cases,  79  per 
per  cent  were  by  gun-shot,  16  per  cent  by  shells,  while 
the  injuries  from  sabres  and  lances  formed  only  about  5 
per  cent,  and  by  bayonet  about  0.4  per  cent.  Still  more 
apparent  are  the  relations  in  the  statistics  of  the  war  of 
1870-71.!  Here  the  entire  loss  of  the  Prussian  army 
amounted  to  65,610  men,  86  per  cent  of  whom  were  from 
gun-shot  wounds,  and  7.8  per  cent  from  injuries  produced 
by  large  shot  and  splinters  of  shells.  If,  in  addition,  we 
subtract  .4  per  cent  for  injuries  in  which  an  accurate  desig- 
nation of  the  weapon  inflicting  them  is  lacking,  the  remain- 
der accounts  for  wounds  which  were  due  to  the  sabre-cuts, 
blows  from  the  butts  of  guns,  bayonet  or  lance  thrusts,  in- 

*  Militar-Wochenblatt,  1867,  p.  244. 

f  G.  Fischer,  Statistik  der  in  dem  Kriege  1870-71  im  preussischen 
Heere  vorgekommenen  Verwundungen  und  Todtungen.  Berlin, 
1876;  p.  6. 

%  Esmarch,  Die  antiseptische  Wundbehandlung  in  der  Kriegschirurgie. 
Verhandl.  des  V.  Congresses  d.  deutsch.  Gesellsch.  f.  Chir.  I.,  p.  13  to 
17  (Discussion),  and  II.,  p.  104. 


SURGICAL  EMERGENCIES.  193 

juries  from  fragments  of  stone  and  earth,  and  from  explo- 
sions of  mines,  as  well  as  burned  wounds. 

Since  we  have,  therefore,  to  deal  chiefly  with  shot- 
wounds,  produced  by  the  action  of  projectiles  from  small 
arms,  our  attention  in  the  application  of  immediate  dress- 
ings must  be  chiefly,  and  with  especial  regard  to  the  attain- 
ment of  aseptic  conduct  of  the  wound,  directed  to  the 
prevention  of  the  entrance  of  all  impure  substances  which 
could  excite  decomposition  within  the  wound. 

As  the  first  protective  measure,  in  a  negative  sense,  is 
to  be  regarded  the  limitation,  as  far  as  possible,  of  digital 
examination  of  the  wound,  in  case  the  finger  cannot  be 
amply  disinfected,  which  is  only  rarely  possible  on  the  bat- 
tle-field even  under  most  favorable  circumstances.  In  op- 
position to  the  indication  which,  even  at  the  beginning  of 
the  Franco-German  war,  was  still  enjoined  upon  surgeons  to 
acquaint  themselves  as  early  as  possible  with  the  nature  of 
the  injury  by  the  introduction  of  the  finger  into  the  recent 
wound,  we  must  now  emphasize  the  necessity  of  entirely 
omitting  the  primary  examination  of  wounds,  provided  no 
dangerous  haemorrhage  is  present,  and  of  renouncing  an 
accurate  diagnosis  in  favor  of  an  antiseptic  treatment  of 
the  wound.  In  this  method  of  treatment  we  are  confirmed 
by  the  observations,  continually  increasing  in  number,  of 
shot-wounds  healing  by  first  intention,  either  under  a 
slough  or  under  the  employment  of  antiseptic  precautions. 
(Stromeyer,  Pirogoff,  v.  Langenbeck,  Volkmann,  Fischer, 
Socin,  *  Klebs.f) 

To  this  end,  we  must  cover  the  orifices  of  entry  and  exit 
with  substances  which,  on  the  one  hand,  render  any  direct 
contamination  of  the  wound  impossible,  and,  on  the  other 
hand,  contain  so  much  antiseptic  matter  that,  in  case  the 
soiling  of  the  materials  used  for  dressing  is  unavoidable, 
decomposition  could  not  possibly  take  place  among  the 
impurities  which  had  penetrated  into  the  dressing.  The 
significance  of  the  antiseptic  material  in  the  dressing,  as 
affecting  the  secretion  of  the  wound,  is  a  consideration  of 
secondary  importance;  since,  at  most,  it  is  only  in  wounds 
which  go  to  the  field-hospital  for  further  treatment  that  the 
primary  dressing  remains  on  any  length  of  time.     In  the 

*  Socin,  Kriegschirurgische  Erfahrungen.     Leipzig,  1873;  p.  6. 
f  Klebs,    Beitrage   zur  pathologischen  Anatomie  der  Schusswunden. 
Leipzig,  1872;  p.  50,  et  seq. 


104  SURGICAL  EMERGENCIES. 

other  wounds  which  come  to  the  place  of  immediate  dress- 
ing, it  has  only  the  significance  of  a  temporary  protective. 

It  will  be  readily  understood  by  you  that  we  can  employ 
only  a  relatively  small  amount  of  material  for  dressing,  and 
hence  it  follows  that  the  antiseptic  substance  with  which  the 
dressing  is  impregnated  should  be  distributed  uniformly  and 
in  undiminished  quantity  through  the  latter.  Just  here  lies  a 
difficulty  which,  up  to  the  present  day,  must  still  be  re- 
garded as  unsolved.  It  has  been  proposed  to  use  for  these 
immediate  dressings  compresses  of  jute  (balls  of  jute  at- 
tached to  strips  of  gauze),  which  have  been  impregnated 
with  carbolized  resin,  salicylic  acid,  or  chloride  of  zinc, 
then  the  compresses  are  to  be  applied  to  the  wOund  and 
secured  by  bandages  or  cloths.  The  compresses,  with  a 
bandage  or  triangularly-shaped  piece  of  cloth,  wrapped  in 
water-tight  paper  (Esmarch,  /.  c),  should  be  distributed  to 
each  soldier,  and  either  carried  in  the  knapsack  or  attached 
to  a  certain  part  of  the  uniform,  so  that  every  soldier,  if  need 
be,  can  apply  an  immediate  dressing  to  himself  or  his 
comrade. 

It  will  be  more  important  and  more  advantageous  to 
provide  a  certain  number  only  of  soldiers,  and  particularly 
the  hospital  aids,  who  have  been  detailed  beforehand  for 
sanitary  service,  with  a  greater  number  of  specially  packed 
compresses  of  the  sort  above  mentioned.  And  this  on  the 
score  that  the  compresses  which  each  soldier  carries  around 
with  him  in  his  knapsack  or  on  his  clothes,  and  which 
share  in  all  the  exposures  to  which  the  latter,  especially  the 
uniform,  are  subject,  can  only  with  difficulty  retain  the 
properties  of  cleanliness  and  antisepsis  which  are  required 
of  them. 

Carbolic  acid  above  all,  as  a  volatile  antiseptic,  will  very 
quickly  evaporate,  as  we  know  from  investigations  in  re- 
gard to  the  amount  contained  in  the  carbolized  bandages 
prepared  after  Lister's  directions  by  Miinnich  and  P. 
Bruns.* 

Again,  the  compresses  recommended  by  Esmarch,  of 
salicylized  jute,  in  which  the  relative  non-volatility  of 
salicylic  acid  was  brought  into  account,  have  not,  accord- 
ing to  the  experiments  made  by  the  Prussian  Ministry  of 


*  Kaufmann,  Centralbl.  f.  Chir.,  1879,  No.  50;  also  Miinnich,  Deutsche 
militararztliche  Zeitschrift,  1880;  Heft  2,  p.  47-81. 


SURGICAL  EMERGENCIES.  I95 

War,  proved  satisfactory.*  Since  it  is  not  possible  to  unite 
salicylic  acid  intimately  with  the  jute,  the  former  is  de- 
posited in  the  form  of  crystals,  and  these  are  found  among 
the  surrounding  articles,  along  with  the  jute  compresses, 
which  have  been  deprived  of  their  salicylic  acid  and  are  not 
antiseptic,  and  this  if  the  soldier's  coat  has  been  shaken 
but  £  few  times.  Chloride  of  zinc,  too,  falls  out  in  the 
form  of  powder. 

While,  then,  we  insist  upon  the  principle  of  the  antiseptic 
compresses,  we  must  wait  to  see  whether  it  is  possible  to 
saturate  them  with  an  antiseptic  which  will  preserve  for  a 
long  time  its  antiputrefactive  properties. 

In  the  wounded  who  are  capable  of  marching,  who  for 
the  most  part  will  have  slight  wound?  of  the  head  and 
upper  extremities,  the  retention  of .  the  compresses  is 
secured  by  bandages  or  cloths.  For  the  support  of  the 
arm  with  slings,  we  use  large,  triangular  pieces  of  cloth.  In 
case  of  necessity  the  slings  can  be  improvised  from  the 
sleeves  and  skirts  of  coats,  f 

If  possible,  canteens  filled  with  strengthening  drink  are 
distributed  to  the  bandaged  warriors. 

In  regard  to  the  wounded  who  are  not  capable  of  march- 
ing, in  whom,  for  the  most  part,  injuries  of  bones  in  their 
continuity  are  present,  we  will,  during  their  transportation 
to  the  place  of  permanent  dressing,  apply  of  course  the 
same  antiseptic  compresses;  but,  to  enable  them  to  under- 
go the  necessary  transportation,  splints  must  also  be 
applied,  which  will  secure  in  place  the  ends  of  the  fractured 
bones. 

Such  splints  can  be  improvised  out  of  weapons — bayonets, 
scabbards,  and  even  out  of  branches,  straw,  straw-mats, 
saddles,  cloaks,  etc.  In  the  transportation,  which  for  the 
most  part  will  be  accomplished  by  hand-bearers,  on  stretch- 
ers or  litters,  the  knapsack  will  be  used  as  a  cushion.  (De- 
tails will  be  found  in  the  admirable  work  already  cited, 
the  "  Hand-book  of  the  Practice  of  Military  Surgery,"  by 
Esmarch,  which  must  be  most  earnestly  recommended  to 
every  young  surgeon  for  study.) 

The  stretchers  themselves  are  covered  with  drilling  or 
sail-cloth.      More    rarely    will   it  be    possible    to   carry  on 

*  Verhandl.  des  VIII.  Congresses  d.  deutschen  Gesellschaft.  f.  Chir. 
2.  Sitzung  vom  17  April,  1879;  P-  47  et  seq. 
f  Esmarch,  Handb.  des    Kriegschirurg.    Technik.,  1877;  p.  58. 


I96  SURGICAL  EMERGENCIES. 

transportation  to  any  great  extent  in  ambulances,  and  still 
more  rarely  in  contrivances  slung  from  the  saddles  of 
horses  or  mules.*  Stretchers  can  also  be  improvised  from 
stakes,  or  branches  of  trees  (Smithf)  with  cross-pieces  and 
covered  with  straw-matting.  Short  ladders,  also  guns  with 
coats  spread  over  them,  etc.,  are  applicable. 

As  already  mentioned,  the  only  one  among  surgical 
operations  to  be  employed  upon  the  battle-field  is  the  pro- 
visional arrest  of  haemorrhage  with  the  tourniquet,  or  bet- 
ter still,  the  elastic  bandage  (after  the  plan  of  Esmarch  and 
Bardeleben). 

In  regard  to  the  personnel  necessary  for  the  removal  of 
the  wounded  from  the  battle-field,  it  is  to  be  remarked  that 
we  need  only  a  few  physicians  at  the  place  of  immediate 
dressing,  whose  chief  duty  will  consist  in  the  assortment  of 
the  wounded.  For  the  application  of  the  primary  dressing, 
a  pretty  large  number  of  hospital  aids  is  sufficient. 

A  greater  number  of  men  to  carry  the  injured  is  re- 
quired. To  them  shall  be  assigned,  under  military  direc- 
tion, the  removal  of  those  of  the  wounded  who  are  incap- 
able of  marching.  When,  besides,  there  is  a  great  number 
of  the  wounded  who  can  be  readily  transported,  the  aid  of 
volunteers  to  assist  in  carrying  the  injured  may  come  into 
consideration,  but  onlv  under  the  proviso  that  these  latter 
shall  be  subordinated  ?o  expert  military  direction. 

THE   PLACE    OF    PERMANENT   DRESSING. 

This  forms  the  first  halting-place  beyond  the  battle-field 
for  the  reception  of  those  already  incapable  of  marching, 
or  those  who  would  become  so  in  the  process  of  transporta- 
tion from  the  battle-field  to  the  field-hospital.  The  position 
of  the  place  for  permanent  dressing  must  be  as  secure  a 
one  as  possible,  and  yet  easily  discoverable  and  accessible 
from  the  battle-field. 

For  reception  in  the  place  for  permanent  dressings,  then, 
only  those  of  the  wounded  should  come  who  are  incapable 
of  marching,  and  they  should  be  classified  directly,  accord- 

*  H.  Fischer,  Allgmein  Kriegschirurgie,  p.  301.  Handb.  v.  Pitha 
u.  Billroth. 

f  Smith  (Norway),  Nogle  nye  Transport  midler  for  Saarede.  Kris- 
tiania,  1876;  compare  also  Miihlwenzel,  Internat.  Ausstell.  f.  Gesund- 
heitspflege,  etc.     Briissel,  1876.     Feldarzt,  1876,  Nos.  22,  23,  and  24. 


SURGICAL   EMERGENCIES.  I97 

ing  to  the  severity  of  their  injuries,  into  the  following 
categories: 

1st.  Those  who  are  to  be  transported  immediately  to 
the  rear,  after  application  of  a  dressing  suitable  for  the 
journey. 

2d.  Those  who  are  capable  of  removal  to  the  rear  after 
several  hours'  rest,  or  after  the  performance  of  the  requisite 
operations. 

3d.  Those  unsuited  to  transportation. 

The  classification  of  the  wounded  at  the  place  of  per- 
manent dressing  is  the  most  difficult,  and,  to  the  wounded, 
the  most  important  part  of  the  physician's  duty.  In  great 
measure  it  decides  the  future  fate  of  the  injured  warrior. 
This  duty  must,  therefore,  be  assigned  to  experienced  hands, 
well  schooled  in  military  surgery. 

The  surgical  force  should  not,  as  has  been  so  often  done 
hitherto,  be  massed  upon  the  battle-field,  without  being 
able  to  develop  a  profitable  activity.  It  is  expedient,  there- 
fore, to  have  ready,  at  the  place  of  permanent  dressing,  a 
large  medical  corps,  which,  divided  into  sections,  will  be 
able  to  carry  out  their  varied  and  extensive  labors. 

This  is  not  the  place  to  describe  more  exactly  how  the  medical  staff 
necessary  for  an  action  should  be  organized  for  the  sanitary  detachments 
to  whom  the  work  at  the  place  of  permanent  dressing  is  allotted.  The 
experiences  of  the  Franco-German  war  have  afforded  ideas  something 
like  the  following: 

1  st.  Doubling  the  sanitary  detachments  for  each  army-corps,  so  that 
in  every  case  one  sanitary  detachment  shall  be  assigned  to  each  brigade. 
2d.  Diminution  of  the  permanent  medical  staff  of  the  sanitary  detach- 
ment from  7  or  8  physicians  to  at  most  3  physicians.  3d.  Separation  of 
the  companies  of  men  detailed  for  carrying  the  wounded,  from  the  san- 
itary detail,  so  that  each  half-company  shall,  under  the  command  of  a 
lieutenant  and  the  medical  supervision  of  an  assistant  physician,  be  di- 
rectly subordinated  to  the  brigade.  4th.  The  command  and  supervision 
of  the  sanitary  detachment  should  be  assigned  to  the  physician-in-chief. 
5th.  Omnibus-wagons  should  be  provided  for  the  transportation  of  the 
subordinates  in  the  sanitary  detachment  (hospital-aids,  nurses),  and  these 
again  can  be  used  for  the  transportation  of  the  wounded  to  the  place  of 
permanent  dressing,  when  the  sanitary  detachment  is  in  course  of  estab- 
lishment. In  this  way  the  mobility  of  the  sanitary  detachment  as  a 
whole,  and  the  efficiency  of  its  subordinates,  when  it  is  in  working  order, 
are  increased.  6th.  The  ambulances  are  to  be  assigned  to  the  companies, 
or  rather  half-companies,  of  the  carrier-corps.  7th.  Besides  two  pack- 
wagons  (one  for  the  physicians,  the  other  for  the  subordinates),  the  san- 
itary detachment  should  carry  along  with  it  (a),  an  operating-wagon,  con- 
taining an  operating  tent,  operating  table,  instruments,  antiseptic  ap- 
paratus, and  apothecaries'  stores  (consisting  of  a  large  stock  of  carbolic 
acid,  smaller  quantities  of  chloroform,  chloride  of  zinc,  two  per  cent,  car- 


I98  SURGICAL  EMERGENCIES. 

bolized  vaseline,  morphine  for  subcutaneous  injection,  castor  oil;  also 
still  smaller  quantities  of  the  preparations  of  opium  for  internal  use,  and 
sodium  sulphate,  and  small  quantities  of  the  liquor  ferri  sesquichloridi, 
argenti  nitras,  tinctura  sem.  strychnin,  tannin,  croton  oil,  bicarbonate  of 
sodium,  tinctura  quininae  comp.,  etc,),  {b).  A  dressing-wagon,  with  all 
the  materials  for  an  antiseptic  dressing,  carbolized  jute,  salicylized  cot- 
ton, mull  and  gauze  bandages,  and  flannel  and  linen  bandages  impreg- 
nated with  chloride  of  zinc,  splints  and  splint-materials  (see  below), 
water-proof  textures  (pressed  rubber,  oiled  paper),  adhesive  plaster,  rub- 
ber rings  for  extension,  ice-bags.  Finally  (c),  a  commissary-wagon, 
containing  pea-sausages,  preserved  meat,  rice,  liquor,  wine,  coffee  and 
sugar.  8th.  In  case  of  action,  the  physicians  attending  the  troops  and 
the  physicians  of  field-hospitals  which  are  not  on  duty,  may  be  detailed 
in  accordance  with  the  demands  of  necessity  or  the  requirements  of  the 
surgeon  of  division  or  the  corps-surgeon,  to  a  sanitary  detachment  for 
the  time,  in  which  the  latter  is  in  operation.  9th.  While  the  sanitary  de- 
tachment is  in  active  service,  the  consulting  surgeon  assigned  to  the 
brigade  or  the  division  takes  command  of  it,  being  represented  by  the 
physician-in-chief  of  the  sanitary  detachment.  (Compare  also  V.  Scheven, 
Deutsch  Militararzt  Zeitschr.     1877,  Heft  6,  p.  265.) 

At  the  station  for  dressing,  moreover,  is  the  spot 
where  the  most  experienced  surgeons,  even  if  for  a 
time  only,  must  put  themselves  at  the  head  of  the 
rest  of  the  medical  staff. 

Here  they  will  be  able  to  make  all  their  knowledge  and 
ability  available  to  the  very  fullest  extent.  Here,  where 
the  fate  of  hundreds  and  hundreds  is  decided,  their  counsel 
and  judgment  can  be  of  especial  service,  perhaps  more  than 
in  the  field-hospitals  and  military  depots,  where  the  con- 
sulting surgeons,  for  the  most  part,  have  only  to  enter  upon 
the  after-treatment,  and  that  often  to  the  discouragement  of 
those  who,  for  weeks  and  months  previous,  have  carried  on 
in  the  most  careful  manner  the  medical  treatment  of  the 
patients  entrusted  to  their  charge. 

The  first  duty  of  the  head-surgeon,  at  the  place  of  dress- 
ing, consists  in  the  division  of  the  medical  staff  into  four 
sections,  according  to  the  individual  capacity  of  each  phy- 
sician. As  we  shall  see,  a  special  duty  is  assigned  to  each 
one  of  these  sections. 

The  surgeon  himself  takes  his  place  at  the  head  of  the 
first  section,  and  in  connection  with  it  undertakes  the  as- 
sortment of  the  wounded  as  they  are  from  time  to  time 
brought  in  to  the  place  of  permanent  dressing.  Differently 
colored  tickets  are  now  attached  to  the  breasts  of  each 
of  the  wounded,  to  distinguish  them  most  readily,  accord- 
ing to  the  categories  which  have  been  already  given.  These 
tickets  should  have  printed  on  both  sides  a  single  word  to 


SURGICAL  EMERGENCIES.  I99 

signify  the  different  divisions.  Thus,  on  the  yellow  card 
the  word  "  Immediate"  can  be  printed;  on  the  blue  card, 
the  words  "To  wait;"  on  the  red  card,  the  words  "To 
remain." 

Previous  to  the  present  time,  in  place  of  the  tickets 
here  recommended,  the  so-called  "  Diagnosis  cards"  were 
introduced  and  distributed  in  great  numbers  among  the 
physicians.  On  these  cards  the  physicians  were  to  desig- 
nate, as  accurately  as  possible,  the  result  of  their  primary 
examinations. 

These  cards  take  their  origin  from  the  time  when  primary 
digital  examination  of  wounds  was  strenuously  enjoined. 
It  must  be  laid  to  the  charge  of  these  cards  and  of  the  de- 
sire to  make  as  accurate  and  correct  diagnoses  as  possible, 
that  fingers  have  been  thrust  into  so  many  wounds  which, 
without  this  exploration,  might  have  healed  without  delay. 
Blood,  rain,  or  dust  often  render  the  hastily  written  and 
scarcely  legible  characters  indistinguishable..  The  diagno- 
sis-card was  written  to  no  purpose,  and  to  no  purpose  was 
the  life  of  the  wounded  man  sacrificed. 

The  different  colored  cards  which  are  recommended,  have 
the  object  of  facilitating,  at  the  dressing-station,  only  the 
supervision  of  the  assortment  and  grouping  of  the  injured. 

The  second  separate  medical  section  has  to  do  with  that 
division  of  the  wounded  who,  after  the  application  of  a 
dressing  suitable  for  the  journey,  are  to  be  conveyed  directly 
to  the  rear.  In  this  division  belong  all  injuries  (of  soldiers 
incapable  of  marching)  which  require  no  immediate  oper- 
ative interference;  more  particularly  all  shot- wounds  of  the 
soft  parts,  all  shot-wounds  of  the  joints,  and  all  wounds  pro- 
duced by  shots  glancing  off  without  solution  of  continuity 
of  bone.  So,  too,  shot-wounds  of  the  lungs,  without  haemop- 
tysis, and  wounds  of  the  abdomen,  without  intestinal 
prolapse. 

In  all  these  cases,  the  region  of  the  injury  is  to  be  care- 
fully cleansed,  and  a  Lister  dressing  (if  possible  under  the 
carbolic  spray)  applied;  and  for  this  purpose  we  will  em- 
ploy carbolized  jute  (Munnich*),  or  dry  jute  saturated  with 
chloride   of   zincf,  either  in  the  form  of   flat  layers  or  of 


*  Miinnich,  Ueber  die  Verwendbarkeit,  etc.  Deutsche  milifararztl. 
Zeitschrift,  1877.     VI.  Jahrgang  Heft  10. 

f  Kohler,  Ber.  liber  die  Klinik  von  Bardeleben  pro  1878.  CharitG 
Annalen,  5  Jahrg.  1880,  p.  563, 


200  SURGICAL  EMERGENCIES. 

cushions  packed  in  sacks  of  antiseptic  gauze.*  Here,  too, 
the  carbolized  gauze  prepared  by  P.  Brunsf  in  the  cold  way 
might  be  employed.  The  securing  of  the  antiseptic  dress- 
ing is  accomplished  on  the  extremities  by  the  aid  of  simple, 
starched  gauze  bandages,  moistened  with  a  3  to  5  per  cent 
solution  of  carbolic  acid;  on  the  chest,  abdomen,  shoulder 
and  hip,  with  the  addition  of  a  few  strengthened  bandages 
of  gauze,  or  flannel,  or  linen  bandages,  which  have  been 
previously  impregnated  with  a  10  per  cent  solution  of 
chloride  of  zinc. 

Drainage  of  wounds  is  to  be  employed  only  exceptionally, 
in  order  not  to  hinder  a  possible  healing  by  first  intention. 

To  determine  the  course  of  the  wound,  it  appears  to  be 
of  importance  to  discover  the  attitude  in  which  the  injury 
was  received,  in  order  the  more  easily  to  discover  the 
course  of  the  projectile,  by  subsequent  imitation  of  this 
attitude.  In  the  second  place,  special  attention  must  be 
directed  to  the  nature  of  the  pieces  of  garments  (or  armor) 
in  the  neighborhood  of  the  wound  of  entry,  in  order  to  be 
able  to  judge  beforehand  whether  any  particles  of  the 
clothing,  etc.,  and  if  so,  how  many  and  what  ones,  have 
been  carried  into  the  canal  of  the  wound. 

Again,  in  injuries  of  this  class,  even  if  no  fractures  are 
present,  we  will  generally  proceed  to  the  application  of 
splints,  because  this  contributes,  on  the  one  hand,  to  secure 
and  firm  compression  of  the  parts,  on  the  other  hand,  to 
the- immobilization  of  the  joints. 

In  part  we  can  employ  ready-made  splint  apparatus;  for 
example,  tin-splints  (Volkmann),  wire-hose  (Mayor,  Bon- 
net, Roser),  etc.  In  great  measure  we  shall  be  able  to 
readily  improvise  splints  from  materials  corresponding  to 
those  above  given;  for  instance,  from  wire-sieves,  from 
wood-ware  (Gooch,  Schnyder,  Esmarch),  or  from  zinc-plate 
(Guillery,  SchoenJ),  etc.     In  regard  to  splints  improvised 


*  Corresponding  somewhat  in  form  and  size  to  the  marks  of  identifica- 
tion as  they  were  used  in  the  American  war,  and  as  they  are  pictured  in 
Gurlt,  Abbildungen  zur  Kraukenpfiege  in  Felde  nach  besten  Hodellen 
der  pariser  Austellung  rom  J.,  1867,  Taf.  XVI.,  Fig.  10. 

f  Paul  Bruns,  Zur  Antiseptik.  in  Kriege.  Arch.  f.  Klin.  Chirurgie,  1879. 
Bd.  XXIV.,  Heft  2,  also  Deutsche  militararztl.  Ztschr.,  1879;  Heft  12, 
pp.  609-617,  and  ditto,  1880,  Heft  I.,  p.  42. 

£  Neuber,  Ein  antiseptischer  Danerverband  Archiv.  f.  klin.  Chir.,  1879. 
Bd.  XXIV.,  Heft  2,  und  the  same.  Ueber  den  antiseptischen  Polster- 
verband  Verhandl.  des  IX.  Congr.  d.  deutschen  Gesellsch.  f.  Chir. 


SURGICAL  EMERGENCIES.  201 

from  branches,  bundles  of  straw,  bayonets,  scabbards,  and 
guns,  compare  Esmarch.* 

As  regards  means  of  transportation  from  the  place  of 
dressing  to  the  field-hospital,  or,  in  case  stations  for  the 
removal  of  the  sick  by  rail  (by  "  sanitary  trains"),  are  to 
be  found  at  not  too  great  a  distance,  in  their  transportation 
home  we  must  employ  the  same  apparatus  which  we  have 
already  learned  to  use  for  transportation  from  the  battle- 
field to  the  place  of  dressing.  Only  now  removal  by  wagons 
or  contrivances  of  similar  nature  predominates  over  re- 
moval upon  stretchers  by  hand-bearers. 

At  the  international  exhibition  of  hygiene  and  life-saving 
apparatus  in  Brussels  in  the  year  1876,  the  ambulance 
wagons  of  E.  Mayer,  in  Hanover,  met  with  most  general 
favor. 

But  in  general,  wagons  which  have  been  prepared  before- 
hand for  the  removal  of  the  wounded,  whether  belonging 
to  the  military  equipment  or  to  the  volunteer  sanitary 
corps,  very  soon,  in  the  course  of  great  battles,  are  found 
to  be  inadequate.  Accordingly,  it  will  be  our  duty,  even 
in  time  of  peace,  to  concern  ourselves  with  the  adaptation 
of  the  ordinary  traveling  conveyances  proper  to  each  coun- 
try, to  the  special  object  of  the  transportation  of  the 
wounded.  Every  new  idea  in  this  department,  no  matter 
from  what  side  it  may  come,  will  be  received  the  more 
thankfully,  in  that  it  exposes  neither  the  State  nor  the  vol- 
unteer sanitary  corps  to  especial  expense  in  time  of  peace, 
as  has  been  hitherto  very  often  the  case  when  people  al- 
lowed themselves  to  be  employed  in  making  very  expensive 
ambulances,  which  should  be  as  convenient  as  possible,  and 
specially  constructed  for  containing  the  greatest  possible 
number  of  patients.  The  experiences  of  the  Franco-Ger- 
man war,  and  of  the  last  Russian  campaign,  have  satisfac- 
torily proved  that  such  ambulances  are  available  only  on 
favorable  ground.  In  the  absence  of  a  good  road,  in  swampy 


*  Weisbach,  Deutsche  militararztl.  Zeitschrift.,  1877;  Heft  II. 

f  Esmarch,  Handb.  d.  Kriegschir.  Technik.,  p.  34. 

%  Catalogue  de  l'expos.  internat.,  etc.  a  Bruxelles,  1876;  p.  104;  and 
"Specialschrift  nebst  Abbildungen  des  Vereins  zur  Pflege  der  verwun- 
deten  und  Krauken  Krieger."  Hanover.  Furthermore  :  Peltzer,  Das 
MilitarsanitUtswesen,  etc.     Berlin,  1877. 

%  Riaut,  Le  materiel  de  secours  de  la  societ6  francaise  a  l'exposition 
de  1878. 


202  SURGICAL  EMERGENCIES. 

regions  or  in  mountainous  districts,  they  have  proved 
useless. 

We  will  endeavor,  then,  to  arrange  the  local  means  of 
conveyance  (two-wheeled  carts,  kibitki,  wagons  arranged 
with  racks,  etc.),  for  the  comfortable  disposition  of  the 
wounded,  and  this  we  shall  accomplish  best  by  the  dis- 
position of  the  latter  upon  stretchers.  The  best  example  of 
how  this  is  accomplished  is  supplied  us  by  the  model  of 
the  Norwegian  peasant-wagon  (Smith,  /.  c),  at  the  Brussels 
Exhibition  of  1876.  Another  is  the  contrivance  for  trans- 
portation on  two-wheeled  carts,  from  the  Paris  Exhibition 
of  1878,  which  we  will  find  on  p.  41  of  Riaut's  "  Report." 
And  still  another  is  the  noteworthy  summary  in  regard  to 
the  transportation  of  the  wounded  by  the  aid  of  beasts  of 
burden,  contained  in  circular  No.  9  of  the  American  War 
Department,*  issued  March  1,  1877. 

To  the  third  section  of  the  medical  staff  is  to  be  assigned 
another  class  of  injuries,  under  which  are  arranged  all  such 
as  require  immediate  operative  interference,  and  which  we 
have  provided  with  a  blue  ticket  ("  To  wait ") .  Since  here 
we  have  to  do  with  the  performance  of  major  surgical  op- 
erations, the  best  operative  ability  must  be  brought  to- 
gether in  this  section. 

In  the  division  just  described   belong: 

1.  All  bleeding  wounds.  Here  the  different  means  for 
the  immediate  arrest  of  haemorrhage  are  to  be  applied,  and 
above  all  the  detection  of  the  bleeding  vessel;  and  for  this 
purpose  a  free  incision  of  the  path  of  the  shot  will  often  be 
necessary. 

2.  All  injuries  of  vessels,  even  when  no  bleeding  occurs, 
on  the  spot.  In  all  such  cases,  central  and  peripheral  liga- 
tion is  to  be  performed,  with  or  without  excision  of  the 
portion  of  the  vessel  ruptured  or  penetrated  by  the  shot. 

3  and  4.  Shot-wounds  of  bones  and  joints,  with  comminu- 
tion. These  injuries  will  be  treated  according  to  the  rules 
for  the  antiseptic  treatment  of  complicated  fractures, 
whether  we  consider,  with  Volkmann,f  the  correct  proceed- 
ing to  be  extensive  incision  of  the  path  of  the  shot,  laying 
bare  the   seat  of  fracture,  removal  of  all  loose  splinters, 

*  Otis,  A  report  to  the  Surgeon-general  on  the  transport  of  sick  and 
wounded  by  pack  animals.     Circular  No.  9. 

f  R.  Volkmann,  Die  Behandlung  der  complicirten  Fracturen.  Samuel 
Klin.  Vortr.  1877,  Nos.  117-118. 


SURGICAL  EMERGENCIES.  203 

thorough  disinfection  of  the  wound,  etc.,  or  whether  in 
correspondence  with  the  experience  of  Reyher*  and  Berg- 
mannf  in  the  Turco-Russian  war,  we  venture  the  endeavor 
to  obtain  a  cure,  under  a  rigidly  antiseptic  protective  dress- 
ing, without  making  any  attack  upon  the  comminuted 
fracture  itself  until  the  subsequent  course  of  the  case 
shows  the  impossibility  of  a  cure  by  antiseptic  means. 

5.  All  injuries  of  the  bones  of  the  skull;  especially  such 
as  penetrate  to  the  brain.  Here  we  shall  have  to  proceed 
entirely  according  to  the  rules  given  under  3  and  4.  Ex- 
cept that  here  the  active  mode  of  procedure  (laying  bare 
the  site  of  fracture,  extraction  of  loose  splinters,  applica- 
tion of  chloride  of  zinc,  drainage,  Lister  dressing)  is  still 
more  expedient  on  account  of  the  irritation  which  the  brain 
suffers  through  fragments  of  bone  which  press  upon  it. 
Moreover,  Soring  by  the  procedure  here  described,  has  ob- 
tained very  remarkable  results  in  the  analogous  injuries 
sustained  during  a  time  of  peace  (see  Lecture  XI). 

6.  Shot  wounds  of  the  larynx.  For  these  we  have  al- 
ready pronounced  the  performance  of  tracheotomy  as  an 
act  of  prophylaxis  necessary  for  every  case. 

7.  Shot-wounds  of  the  lungs,  with  haemoptysis.  Here 
it  must  be  left  to  the  judgment  in  each  case  by  itself, 
whether  in  addition  to  the  subcutaneous  injection  of  mor- 
phine, venesection  should  be  performed  or  not  (see  Lecture 
VI.) 

8.  Shot-wounds  of  the  abdomen,  with  prolapse  of  the 
intestines.  After  cleansing  and  subsequent  suture  of  the 
intestine,  the  latter  is  to  be  replaced  and  a  suture  applied 
to  the  abdominal  wall. 

9.  Shot-wounds  of  the  bladder.  If  in  these  it  be  pos- 
sible to  introduce  a  catheter,  it  ought  to  be  left  permanently 
in  the  bladder  to  effect  a  continuous  removal  of  the  urine. 
If  the  urethra  is  injured  and  impassable  at  the  time,  an  open- 
ing into  the  bladder  must  be  made  immediately,  and,  in 
addition,  external  urethrotomy  performed,  with  the  intro- 
duction of  a  permanent  catheter  (see  treatment  of  shot- 


*  Reyher,  Die  antiseptische  Wundbehandlung  in  d.  Kriegs.  Chirurgie. 
Samuel  Klin.  Vortrage,  Nos.  142  to  143. 

f  Bergmann,  Die  Behandlung  der  Schusswunden  des  Kniegelenks  im 
Kriege.     Stuttgart,  1878. 

\  Socin,  Zur  Behandlung  der  Kopfoerletzungen.  Corresponderzblatt 
f.  schweizer  terzte,  1876,  No.  24. 


204  SURGICAL  EMERGENCIES. 

wounds  of  the  bladder,  p.  157  ;  and  also  posterior  catheteri- 
zation, p.  153). 

10.  Shot-wounds  of  the  testicles.  These  are  among  the 
most  painful  of  gun-shot  injuries.  They  are  to  be  treated 
together  with  the  administration  of  morphine,  by  antiseptic 
compression  and  suspension. 

11.  Shattering  of  entire  extremities.  Most  frequently 
occurring  from  the  action  of  fragments  of  shells.  Here 
amputation  is  called  for. 

The  performance  of  resections  at  the  dressing-station  is  to 
be  confined  within  the  narrowest  limits  possible,  and  to  be 
deferred  to  the  field-hospital.  When  antisepsis  is  rigidly 
carried  out,  resections  can  generally  be  performed  as 
secondary  operations. 

We  turn,  finally,  to  the  last  class  of  the  wounded  (red 
cards  with  "  To  remain"  upon  them),  who,  as  not  capable 
of  transportation,  must  remain  at  the  dressing-station. 
Should  the  wounded  of  this  class  survive  their  injuries, 
their  removal  would  be  ordered  when  all  the  other  patients 
had  been  removed  from  the  dressing-station. 

Hereto  belong  : 

1.  All  who  are  excessively  exsanguinated. 

2.  All  who  are  unconscious. 

3.  All  head  injuries  with  considerable  hernia  of  the 

brain  or  extensive  injury  to  the  brain-substance. 

4.  Injuries  of  the  spinal  column  and  of  the  pelvis,  the 

latter  especially  if  associated  with  comminution  or 
extensive  solution  of  continuity. 

5.  Multiple  severe  injuries. 

The  patients  here  considered,  who  are  to  be  transferred 
to  section  four  of  the  medical  staff,  need  especially  careful 
attention  and  a  continuous  intelligent  supervision,  in  order 
to  save  what  yet  is  capable  of  being  saved. 

More  particularly  in  head-injuries  of  this  class  it  might 
be  that  antisepsis  would  afford  happier  results  than  such  as 
we  had  the  mournful  opportunity  of  witnessing,  together 
with  the  indescribable  distress  associated  with  them,  at  the 
dressing-stations  in  the  Franco-German  war. 

For  these  patients  it  is  above  all  things  necessary  to  pro- 
cure as  good  and  as  secure  quarters  as  possible,  since,  as 
has  already  been  said,  we  must  delay  their  removal  almost 
up  to  the  time  of  the  cessation  of  our  activity  at  the  dress- 
ing-station; and  only  in  cases  where  our  duty  concerns  not 
the  victorious  but  the  defeated  and  retreating  army,  will 


SURGICAL   EMERGENCIES.  205 

the  removal  to  the  rear  be  accelerated  in  accordance  with 
the  strength  of  those  who  are  most  severely  injured. 

So  you  see  that  the  complicated  and  often  excessive  labor 
at  the  dressing-station  can  be  carried  on  in  the  most  efficient 
manner,  if  in  every  case  of  injuries  to  numbers  of  men  we 
follow  the  important  principles  of  division  of  labor  and 
harmonious  cooperation  of  the  working  forces. 


INDEX. 


Abdomen,  indications  for  evacua- 
ation  of  fluid  in,  147 
operation    for    puncture 

of,  148 
sites   for    evacuation    of 

fluid  in,  147 
exploratory  puncture  of, 
149 
Abscess,  cerebral,  172 

diagnosis  of  cerebral,  172 
of  brain,  diagnosis,  177 
Abnormal  anus,  125 
Absence  of  sigmoid  flexure,  126 
Accidents  to  numbers,  9 
Actual  cautery  in  haemorrhage,  48 
Acupressure,  40 
Acupuncture  of  heart,  144 
Acute  invagination,  symptoms  of, 

106 
Accumulations    of   blood   in    peri- 
cardium, 144 
of  fluid   within  tho- 
rax, 130 
of    blood    in    small 
vessels,  17 
Air-supply  in  cases  of  suffocation 

and  poisoning,  11 
Anus,     supra-inguinal      operation 
for  artificial,  128 
"     imperforate,  126 
"     imperforate,  operations    for, 

126 
"     abnormal  J  25 
Antiseptic  thread  ligature  at  point 
of  injury  of   arteries, 

35 
sponges,  tampon  of,  26 
Aneurism,  ligation  in,  35 
Aneurismal    varix,  formation    of, 

after  wounds  of  vessels,  27 
Anatomy  of  pre-tracheal  region,  91 
Anaemia,  transfusion  in,  68 


Aorta,  compressors  for,  38 
Apoplexy, cerebral,  bleeding  in,  51 
Apparatus  for  cupping,  56 
Application  of  Esmarch's  bandage, 
24 
of   ligature    to   injured 
artery,  32 
Arrest  of  haemorrhage,  means  for, 
22 
"      of  bleeding   from    arteries, 

26 
"      of     bleeding      from     leach 
bites,  57 
Arterial   wounds,  central   ligation 

in,  35 
Artery,  method  of  ligation,  32 
"        haemorrhage  from  middle 

meningeal,  166 
"        hooks,  33 

"        ligation    of   main,  in  ven- 
ous haemorrhage,  43 
ligation  of  middle  menin- 
geal, 168 
Arteries,  compression  of,  with  in- 
struments, 38 
"        antiseptic     thread      liga- 
ture of,  at  point  of  in- 
jury, 35 
"        arrest  of   bleeding  from, 
26 
Arteriotomy,  54 
Artificial  leech,  56 
Artificial  respiration  in  chloroform 
poisoning,  79 
"        respiration  after  tracheo- 
tomy, 88 
"        respiration  in  opium  poi- 
soning, 79 
Atresia  ani,  126 

"    operation  for  relief  of, 
126 
Auto-Tranfusion,  71 


208 


INDEX. 


Bandage,    Esmarch's,  method   of 

application,  24 
Bellocq's  catheter,  44 
Bladder,  causes  of  injuries  to,  157 
Bleeding  from   leech   bites,   arrest 

of,  57 
' '        in  pulmonary  hyperemia, 

5i 
"        in  pneumonia,  51 
"        in  cerebral  apoplexy,  51 
as  a  haemostatic,  50 
arrest   of,  from   arteries, 
26 
■'        of  plethoric    individuals, 
16 
Blood,  gaseous  constituents  of,  in 
transfusion,  61 
"      corpuscles,    red,     viability 

of,  60 
"      changes     in,     in    carbonic 

acid  poisoning,  81,  82 
"      subcutaneous  injection  of, 

66 
"      saving  of,  22 
"      compensation   for  loss  of, 

22 
"      loss  of,  compensation  for, 

22 
"      stopping  of,  22 
"      loss  of,  13 
"      experimental   increase    of, 

13 
"      accumulation  in  small  ves- 
sels, 17 
"      pressure  curve,  relation  to 

rapidity  of  bleeding,  19 
"      pressure  curve   after  phle- 
botomy, 18 
"      death  from  want  of  motion 
of,  19 
Brain,  concussion  of,  178 

"        concussion    of,  symptoms, 
182 
Buckle  tourinquet,  39 
Burns,  transfusion  in,  68 

Caissons,  death  from  working  in, 

86 
Capacity  of  vascular  system,  14 
Capillary  haemorrhages,  46 

"  "       tampon  in,  46 

Carbolic  acid  as  a  styptic,  47 
Carbonic  acid   poisoning,  changes 

in  blood  in,  81,  82 


Carbolized  catgut  ligature,  28 
Carotid,  compression  of,  37 

cerebral  haemorrhage 

from,  168 
Catgut  ligature,  carbolized,  28 

"       organization  of,  29 
"       objections  to,  31 
Catheter,  Bellocq's,  44 
Causes  of  stricture  of  oesophagus, 
102 
"      of  irreducibility  of  hernia, 
104 
Cautery,  actual,  in  haemorrhage,  48 
Central  ligature  in  arterial  wounds, 

35 
Cerebral  abscess,  172 

"  "        diagnosis  of,  172 

Cerebral  compression,  164 
Cerebral  concussion,  treatment,  183 
Cerebral  motions,  causes  of,  177 
Changes  in  blood  in  carbonic  acid 

poisoning,  81,  82 
Chloride  of  iron  as  a  styptic,  47 
Chylothorax,  indications  for  opera- 
tion in,  135 
Chemical  haemostatics,  48 
Chloroform     poisoning,     artificial 
respiration  in,  79 
"  poisoning,     tracheo- 

tomy in,  78 
Chronic  diseases,  transfusion  in,  69 
Circumsuture,  39 
Classification  of  mortal  dangers,  n 

"  of  wounded,  192 

Cold  in  haemorrhage,  47 
Colotomy,  127 

Compensation  for  loss  of  blood,  22 
Compressed  air  in  poisoning  from 

nitrous  oxide,  87 
Compression  of  arteries  with  in- 
struments, 38 
"  of  carotid,  37 

"  of    external    maxil- 

lary, 36 
"  of  femoral,  37 

"  of  radial,  37 

"  of  subclavian,  37 

"  cerebral,  164 

"  digital,  36 

Compressors  for  aorta,  38 
Concussion,-  cerebral,    treatment, 

179 
Concussion  of  brain,  178 

"  "  pathology,  179 


INDEX. 


209 


Concussion  of  brain,  symptoms,  182 
Considerations,  general,  9 
Contraction  of  cavity  of  skull,  161 
"  "  me- 

chanism of,  162 
Croup,  tracheotomy  in,  76 
Cupping,  56 

"        apparatus  for,  56 
dry,  56 
Cystotomy,  153 

"  indications  for,  153 

"  supra-pubic,  156 

"  supra-pubic,  operation 

of,  156 
"  through  rectum,  155 

Danger     of     defribrinated    blood 
transfusion,  62 
"       of  entrance  of  air  in  thora- 
centesis, 140 
Dangers,  mortal,  classification  of, 

11 
Death,  causes  of,  from  slow  suffo- 
cation, 83 
"       from  haemorrhage,  18 
"       from   want    of    motion    of 
blood,  19 
Dental  haemorrhage,  liq.  ferri  ses- 

qui-chlor.  in,  47 
Decompression   of   divers,  inhala- 
tion of  oxygen  in,  87 
Digital  compression,  36 
Digitalis  as  a  haemostatic,  49 
Dilatation  of  strictures  of  oesopha- 
gus, 102 
Diphtheria,  tracheotomy  in,  76 
Disadvantages  of  Esmarch's  meth- 
od, 25 
Divers,  death  from  accident,  86 
Douche,  hot,  in  haemorrhage,  47 
Double  puncture,  151 
Dry  cupping,  56 
Dyspnoea  from  transfusion,  68 

Echinococci  of  kidney,  152 
Echinococcus,  treatment  of,  150 
Electric  current,  application  of,  in 

haemostasis,  26 
Electro-puncture  of  heart,  145 
Elements,  vital,  loss  of,  13 
Empyema,  evacuation  of  fluid  in, 

133 
Enteroraphy,  115 
Epistaxis,  treatment  of,  44 


Ergotine,  as  a  haemostatic,  48 
Esmarch's  bandage,  23 

"  bandage,  method  of  ap- 

plication, 24 
"  method,  advantages  of, 

22 
"  method,     disadvantages 

of,  25 
"  rubber  tube,  23 

Experimental  increase   of   amount 

of  blood,  13 
Experiments  with  catgut  ligature,  29 
Exploratory  puncture  of  abdomen, 

149 
External    maxillary,    compression 

of,  36 
External  pressure  in  obstruction  of 

oesophagus,  99 
Extravasation  of  blood  in  brain,  164 

False  reduction  of  hernia,  no 
Femoral,  compression  of,  37 
Fibrin  ferment  in  transfusion,  61 
Fistula,  gastric,  closure  of,  125 

"        spontaneous  gastric,  121 
Fluid  in  abdomen,  146 

"  "  differential  diag- 

nosis, 149 

"  "         indications     for 

evacuation  of, 

147 
"  "  sites  for  evacua- 

tion of,  147 
Fluid  in  air-passages,  treatment,  92 
"     in  thorax,  130 
"     in  thorax,  historical  consider- 
ation, 131 
"     in     thorax,    indications    for 
evacuation,  131 
Fluid  within  the  uterus,  159 

"  "        causes  of,  159 

Forceps    for    removal    of    foreign 

bodies  from  oesophagus,  98 
Foreign    bodies    in    bronchus,    re- 
moval of,  74 
"  "         in  larynx,  remov- 

al of,  74 
"  "         in  oesophagus,  98 

"  "         in     the     rectum, 

treatment,  128 
"  "         in  trachea,  74 

"  "         in    urethra,    indi- 

cations for  re- 
moval of,  154 


2IO 


INDEX. 


Foreign  bodies  in  vagina,  remov- 
al of,  129 
Fracture  of  skull,  169 

"  '*  antiseptic    treat- 

ment, 171 
"  "  symptoms,  169 

Frequency  of  venous  haemorrhage, 

Fuming  nitric  acid  as  a  styptic,  47 

Galvano-cautery  in  haemorrhage 

48 
Gaseous  constituents  of  blood  in 

transfusion,  61 
Gastric  fistula,  closure  of,  125 

"  "       spontaneous,  121 

Gastrotomy,  119 

"  after  treatment,  124 

"  feeding  after,  124 

history  of,  121 
"  indications  for,  119 

"  sites  for  incision,  121 

"  operation  of,  121 

General  considerations,  9 
Girard's  method  of  introduction  of 

oesophageal  sound,  103 
Guide  for  introduction  of  oesopha- 
geal sound,  103 

Hanging,  74 
Hsematometra,  159 

treatment,  159 
Haemostasis,  11 

application  of  electric 
current  for,  26 
"  spontaneous,  19-26 

"  spontaneous     from 

small  veins,  42 
Hsemostatic,  bleeding  as  a,  50 
"  chemical,  48 

digitalis  as,  49 
"  ergotine  as  a,  48 

lead  acetate  as  a,  49 
liq.  ferri  sesqui-chlor 

as  a,  48 
silver  nitrate  as  a,  48 
tannic  acid  as,  48 
Haemorrhage,  actual  cautery  in,  48 
"  between     dura    and 

pia  mater,  169 
11  capillary,  46 

"  capillary,  tampon  in, 

46 
"  cold  in,  47 


Haemorrhage,  death  from,  18 

dental,  liq.  ferri  ses- 
qui-chlor in,  47 

galvano-cautery  in, 
48 

from  cerebral  car- 
otid, 168 

hot  douche  in,  47 

from  intercostal  ar- 
tery, method  of  ar- 
resting, 139 

from  meningeal  ar- 
tery, 166 

from  middle  menin- 
geal artery,  166 

means  for  arresting, 
22 

within  thorax,  indi- 
cations for  opera- 
tion, 135 

pigment  in  relation 
to,  20 

phlebostatic,  42 

qualitative  change  of 
blood  in,  20 

relation  to  blood- 
pressure  curve,   19 

secondary,  in  punc- 
tured wounds,  34 

secondary,  from 

bruises  of  balls,  28 

venous,  frequency 
of,  41 

venous,  tampon   in, 

43 
venous,    ligation  of 
artery  in,  43 
Heart,  acupuncture  of,  144 

"      electro-puncture  of,  145 
Hernia,  103 

"       dangers  of  invagination  of, 

105 
"        differential  diagnosis,  107 
"       false  reduction  of,  no 
"       incarcerated,  104 
"       invagination  of,  105 
"       irreducible,  104 
"       radical  cure  of,  117 
"        symptoms  of  strangulation, 

106 
"        taxis  in,  106 
"       treatment  of,  107 
"        treatment  of  strangulated, 

108 


INDEX. 


211 


Hernial  contents,   104 
"      neck,  104 
"       sac,  104 

"     orifice  of,  104 
"     peritonitis  within,  107 
"       strangulation,  site  of,  107 
Herniotomy,  111 

history  of,  in 
operation  of,  11 1 
internal,  112 
treatment  of  gangren- 
ous intestine,  114 
after  treatment,  117 
History  of  Transfusion,  57-58 
Hooks,  artery,  33 
Hot  douche  in  haemorrhage,  47 
Hydronephrosis,  treatment  of,  152 
Hydropericardium,  indications  for 

operation,  142 
Hyperemia,    pulmonary,   bleeding 

in,  51 
Hypogastric  puncture,  155 

Immediate  dressing  of  wounds,  192 
Imperforate  anus,  126 

"    operation  for,  126 
Incarcerated  hernia,  104 
Increase,  experimental,  of  amount 

of  blood,  13 
Incisions  for  cesophagotomy,  100 
Indications  for  local  bleeding,  55 

for  cesophagotomy,  100 
Inflammatory  invagination,  107 
Infra-glandular  tracheotomy,  89 
Inhalation    of    oxygen   in   decom- 
pression of  divers,  87 
Injuries  of  heart,  prognosis  of,  144 
"      of  bladder,  causes,  157 
"      to     bladder,     intra-perito- 

neal,  prognosis  of,  158 
"      to  walls  of  cerebral  sinuses, 
165 
Injury  of  skull,  treatment,  172 
"       of  vessels,  ligature  in,  28 
"       to  brachial  artery  in  phlebot- 
omy, 54 
Injection,   subcutaneous,   of  blo.od, 

66 
Instruments  for  removing  foreign 

bodfes  from  urethra,  155 
Intestinal  canal,    impediments  in, 

97 
Intussusception,  107 
Internal  herniotomy,  112 


Intestine,  resection  of,  115 
Invagination,  acute,  symptoms  of, 
106 
"  subacute,  106 

inflammatory,   107 
spasmodic,  107 
of  hernia,  dangers  of, 
105 
Irreducible  hernia,  104 
Irreducibility  of  hernia,  causes  of, 
104 

Kidneys,  echinococci  of,  152 
Kolpeurynter,  44 
Kropftod,  76 

Laparo-colotomy,  127 
Laryngeal    injuries,      tracheotomy 

for,  74 
Laryngo-tracheotomy,  90 
Lead  acetate  as  a  haemostatic,  49 
Leech,  application  of,  57 
"       artificial,  56 
"       bites,    arrest    of     bleeding 
from,  57 
Ligature  of  injured  vessels,  28 
antiseptic  silk,  31 
antiseptic  thread,  at  point 
of  injury  of  arteries,  35 
carbolized  catgut,  28 
catgut,  organization  of,  29 
catgut,  objections  to,  31 
"         Chinese  silk,  32 

common    thread,    carbol- 
ized, 32 
horse-hair,  31 
hemp,  32 
permanent  substitutes  for, 

36 
provisory  substitutes  for, 

36 
sea-weed,  31 

English  silkworm  gut,  32 
"         silver,  32 
Ligation  in  aneurism,  35 

preparatory  to  great  oper- 
ations, 35 
in  p  .nctured  wounds,  34 
of  main  artery  in  venous 

haemorrhage,  43 
of  injured  artery,  32 
of   middle   meningeal  ar- 
tery, 168 


212 


INDEX. 


Liq-ferri  sesquichlor  as  a  haemos- 
tatic, 48 
as   styptic  in 
dental  haem- 
orrhage, 47 
Local  bleeding,  indications  for,  55 
Loss  of  blood,  13 

"      compensation     for, 
22 
Loss  of  vital  elements,  13 
Lumbo-colotomy,  127 

operation  of,  127 

Mass-ligature,  39 

Maxillary,    external,    compression 

of.  36 
Means  for  arresting  haemorrhage, 

22 
Meningeal     artery,     haemorrhage 

from,  166 
Method  of  removing  foreign  bodies 
from  larynx,  74 
"        of  ligating  an  artery,  32 
'■'       Esmarch's,  advantages  of, 
22 
Military  cases,  a  type,  12 
Mortal  dangers,  classification  of,  n 
Motion  of  blood,  death  from  want 
of,  19 

Neck,  hernial,  104 

Nitrous  oxide,   compressed  air  in 

poisoning  from,  87 
Nitric  acid,  fuming,  as  a  styptic,  47 
Nurses,  190 

Objections  to  catgut  ligature,  31 
(Edema  glottidis,  75     ' 
(Esophageal  sound,  99 

"      introduction  of, 
102 
guide    for    in- 
troduction, 
103 
"  "      Girard's   meth- 

od  of   intro- 
duction, 103 
(Esophagus,  sites  of  obstruction  in, 
98 
foreign  bodies  in,  98 
"  resection  of,  101 

removal     of     tumors 
from,  1 01  L 


(Esophagus,  site  of  strictures  of, 
101 
traumatic      strictures 

of,  101 
causes  of  stricture  of, 
102 
"  spasmodic      stricture 

of,  102 
<c  dilatation  of  stricture 

of,  102 
(Esophagotomy,  100 

indications       for, 
100 
"  incisions  for,  100 

"  tracheotomy  pre- 

ceding,   indica- 
tions for,  101 
Opium  poisoning,  artificial  respira- 
tion in,  79 
Organization  of  nursing  corps,  190 
"  of  catgut  ligatures,  29 

Orifice  of  hernial  sac,  104 
Ovarian  cysts,  puncture  of,  152 

Paquelin's  thermo-cautery,  48 
Paralysis  of  vocal  cords,  tracheo- 
tomy in,  77 
"         of  vascular  walls,  25 
Paracentesis  abdominis,  operation 
of,  148 
"  thoracis,  138 

Pericardium,  accumulation  of  blood 

in,  144 
Perineal  puncture,  155 
Peritonitis  within  hernial  sac,  107 
Peritoneal     covering     of     hernia, 

when  absent,  104 
Permanent  substitutes  for  ligature, 

36 
Periphlebitis,  42 
Phlebotomy,  53 

11  blood-pressure  curvt 

after,  18 
"  cleanliness  in,  52 

"  injuries   to    brachial 

artery  in,  54 
Phlebitis,  42 

Phlebostatic  haemorrhages,  42 
Pharyngotomy,  88 
Pigment  in  relation  to  haemorrhage, 

20 
Place  of  permanent  dressing,  196 
Plethoric  individuals,  bleeding  of, 
16 


INDEX. 


213 


Pneumopericardium,     indications 

for  operation,  142 
Pneumothorax,    thoracentesis   for, 

133 

Pneumonia,  bleeding  in-,  51 
Poisoning,  transfusion  in,  68 

and      suffocation,      air 
supply  in,  II 
Prolapsus  cerebri,  178 
Prophylactic  trephining,  184 
Provisory  substitutes  for  ligature, 

36 
Punctured  wounds,  ligation  in,  34 
effect     of,     on 
vessels,  27 
Puncture  of  abdomen,  operation  of, 
148 
hypogastric,  155 
perineal,  155 
Punctio  vesicae,  153 
Pyonephrosis,  puncture  for,  152 

Qualitative  changes  of  blood  in 
haemorrhage,  20 

Radial,  compression  of,  37 
Reasons  for  special  treatise,  9 
Rectum,   foreign   bodies  in,  treat- 
ment, 128 
Reduction  of  hernia,  false,  no 
Relation  of  blood-pressure    curve 

to  rapidity  of  bleeding,  19 
Removal  of    foreign  bodies    from 
bronchus,  74 
"        of    foreign    bodies   from 
oesophagus, forceps  for, 
98 
•'        of  foreign  bodies    from 
vagina,  129 
Resection  of  oesophagus,  107 
of  ribs,  141 
of  intestine,  115 
Ribs,  resection  of,  141 
Rubber  bands,  objection  to  use  of, 

25 
Rupture  of  vascular  system,  14 

Sabre  wounds, effect  of,  on  vessels, 

27 
Sac,  hernial,  104 

"       orifice  of,  104 
Saving  of  blood,  22 
Scarification,  55 
Screw  tourniquet,  39 


Secondary    haemorrhage  in    punc- 
tured wounds,  34 
"  haemorrhage  from 

bruises  of  balls.  28 
Sigmoid  flexure,  absence  of,  126 
Silver,  nitrate,  as  a  haemostatic,  48 
Sinus,  injuries  of  wall  of  cerebral, 

165 
Skull,  antiseptic  treatment  of  frac- 
ture of,  171 
"      fracture  of,  169 
"      injuries  of,  treatment,  172 
"      symptoms  of  fracture  of,  169 
Sounds,  oesophageal,  99 
Spasmodic  invagination,  107 

"  stricture  of    oesophagus 

102 
Special  treatise,  reasons  for,  9 
Spontaneous  haemostasis,  19-26 

"  haemostasis  from 

small  veins,  42 
"  gastric  fistula,  121 

Spring-lancet,  dangers  of,  in  phle- 
botomy, 54 
Starvation,  transfusion  in.  69 
Strangulated  hernia,  treatment  of, 

108 
Strangulation,  74 

"  apparent,  of  hernia, 

107 
"  hernial,  site  of,  107 

Stricture  of  oesophagus,   site  of,  101 
spasmodic,     of      oesopha- 
gus, 102 
of  oesophagus,  causes  of, 

102 
of  oesophagus,    dilatation 

of,  102 
of    trachea,    tracheotomy 

in,  73 
traumatic,  of  oesophagus, 
101 
Stopping  of  blood,  22 
Stoppage  of   air-supply    to    lungs, 

causes  of,  73 
Styptic,  carbolic  acid  as,  47 

chloride  of  iron  as,  4', 
"         fuming  nitric  acid,  47 
Subclavian,  compression  of,  37 
Subcutaneous  injection  of  blood,  66 
Substitutes,  permanent, for  ligature, 

36 
"  for  ligature,  provisory. 


214 


INDEX. 


Suffocation,  slow,  83 

and     poisoning,     air- 
supply  in,  11 
Supra- glandular  tracheotomy,  89 
Supra-inguinal  anus,  operation  for, 

128 
Supra-pubic  cystotomy,  156 

cystotomy      operation 
of,  156 
Surgical  aid  in  war,  189 
Sutures,  lead,  32 
silver,  32 

Tampon  of  antiseptic  sponges,  26 
in  capillary  haemorrhage, 

46 
in   venous     haemorrhage, 

43 
Tannic  acid  as  a  haemostatic,  48 
Taxis,   106 

"        application  of,  108 
Tetanus,  tracheotomy  in,  81 
The  battle-field,  191 
Thorax,  fluid  in,  131 

indications  for  evacuation 

of  fluid  within,  131 
fluid      within,      historical 
consideration,  131 
Thoracentesis  by  corrosion,  136 

dangers  of  entrance 

of  air  in,  140 
indications  for,  136 
by  incision,  136 
by  perforation,  136 
varieties,  136 
.   methods   of  operat- 
ing, 138 
after  treatment,  141 
Thoracotomy,  137 

sites     for    incision, 

137 
Thyro-cricoid  laryngotomy,  88 
Thyroid  laryngotomy,  88 
Topography  at  bend  of  elbow,  52 
Torsion,  40 
Tourniquets,  38 

buckle,  39 

screw,  39 
Trachea,  foreign  bodies  in,  74 
Tracheotomy  in  tetanus,  81 

for      laryngeal      in- 
juries, 74 

infra-glandular,  89 

supra-glandular,  89 


Tracheotomy,  introduction  of  tube, 
92 

as  a  prophylactic  in 
impaction  of  for- 
eign bodies,  75 

in  paralysis  of  vocal 
cords,  77 

in  tracheal  strictures, 

in  chloroform  poison- 
ing, 78 
"  in  diphtheria,  76 

"  in  croup,  76 

"  in  tumors  of  larynx, 

77 
"  artificial    respiration 

after,  88 
preceding        cesoph- 
agotomy,      indica- 
tions for,  102 
Transfusion,  danger  of  defibrinated 
blood,  62 
fibrin  ferment  in,  61 
gaseous    constituents 
of  blood  in,  61 
"  history  of,  57-58 

"  varieties,  60 

"  introduction  of  air  in, 

64 
"  in  starvation,  69 

"  in  chronic  diseases,  69 

operation  of,  66 
"  in  anaemia,  68 

"  in  poisoning,  68 

"  in  burns,  68 

dyspncea  from,  68 
Traumatic  strictures  of  oesophagus, 

101 
Trephining  of  cranium,  183 
"  prophylactic,  184 

"  indications  for,  185 

"  operation  of,  185 

"  after  treatment,  187 

Treatise,  special,  reasons  for,  9 
Treatment  of  epistaxis,  44 

"  of  gangrenous  intestine, 

114 
"  of  strangulated  hernia, 

108 
Tumors  of  abdominal  cavity,  153 
".       of  larynx,  tracheotomy  in, 

77 
"        of  oesophagus,  101 
Twist  tourniquet,  38 


INDEX. 


215 


Tympanites  peritonealis,  150 
puncture  in,  150 


Urethra,  foreign  bodies  in,  154 
Use  of  rubber  bands,  objection  to, 

25 
Uterus,  fluids  within  the,  159 

fluids  within  the,  causes  of, 
159 


Vagina,  removal  of  foreign  bodies 

from,  129 
Valvular  insufficiency  from  air  in 

veins,  65 
Varix,    aneurismal,    formation    of, 

after  wounds  of  vessels,  27 
Vascular  system,  capacity  of,  14 
"        rupture  of,  14 
Vascular  walls,  paralysis  of,  25 
Venous  haemorrhage,  frequency  of, 

4i 
"  ligation       of 

artery     in, 

43 
"  tampon     in, 

43 


Veins,  spontaneous  hsemostasis,  42 

"      at  bend  of  elbow,  52 
Venesection,  indications  for  in  in- 
juries of  skull,  175 
Vessels,     small,    accumulation    of 
blood  in,  17 
"  injury  of,  ligature  in,  28 

"  wounds  of,  followed  by 

aneurismal  varix,  27 
Viability  of  red  blood  corpuscles,  60 
Vital  elements,  loss  of,  13 

War,  surgical  aid  in,  189 
Wounds,   arterial,    central  ligation 
in,  35 
"  of    vessels,    aneurismal 

varix  after,  27 
"  punctured,  effect   of,  on 

vessels,  27 
punctured,     ligation    in, 

34 
immediate    dressing   of, 

192 
sabre,   effect  of,  on  ves- 
sels, 27 
Wounded,  classification  of,  192 

in  war,  treatment  of,  195 
"  transportation  of,  191 


/^Z?33 


^  ^& 


</  <?  *s  s-  <r  ^~ 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  33  L56  C.1 

Surgical  emergencies:  12  lectures  delive 


2002107147 


